Provider Demographics
NPI:1003865593
Name:KANOK, MONTRA M (MD)
Entity Type:Individual
Prefix:
First Name:MONTRA
Middle Name:M
Last Name:KANOK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 E FOOTHILL BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786
Mailing Address - Country:US
Mailing Address - Phone:909-981-5859
Mailing Address - Fax:909-981-8293
Practice Address - Street 1:1030 E FOOTHILL BLVD
Practice Address - Street 2:STE 101
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786
Practice Address - Country:US
Practice Address - Phone:909-981-5859
Practice Address - Fax:909-981-8293
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25649207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A256490Medicaid
CAA25649OtherLIC
CAA25649OtherLIC
A24519Medicare UPIN
CA00A256490Medicare ID - Type Unspecified