Provider Demographics
NPI:1699268631
Name:MONTECRISTO MEDICAL PC
Entity type:Organization
Organization Name:MONTECRISTO MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:EMPERATRIZ
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-568-6923
Mailing Address - Street 1:14649 VICTORY BLVD STE 20
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-4101
Mailing Address - Country:US
Mailing Address - Phone:818-786-8396
Mailing Address - Fax:818-901-7128
Practice Address - Street 1:14649 VICTORY BLVD STE 20
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411
Practice Address - Country:US
Practice Address - Phone:818-786-8396
Practice Address - Fax:818-901-7128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-13
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100277261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care