Provider Demographics
NPI:1003916263
Name:MONTANG, LISA RENEE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:MONTANG
Suffix:
Gender:F
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:PO BOX 22210
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94623-2210
Mailing Address - Country:US
Mailing Address - Phone:510-535-4000
Mailing Address - Fax:510-535-4189
Practice Address - Street 1:1030 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601
Practice Address - Country:US
Practice Address - Phone:510-238-5400
Practice Address - Fax:510-238-5437
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73747207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC11991FMedicaid
CAZZZ79046ZOtherFQHC MEDICARE PART B
CA55-1822OtherFQHC MEDICARE PART A
CAHAP11991FOtherFPACT
CAFHC11991FMedicaid