Provider Demographics
NPI:1174630016
Name:RETAMOZO, MILTON (MD)
Entity Type:Individual
Prefix:
First Name:MILTON
Middle Name:
Last Name:RETAMOZO
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 1:400 N. PEPPER AVE.
Mailing Address - Street 2:MOB SUITE 308 ATTN OLIVIA MENDOZA
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-1801
Mailing Address - Country:US
Mailing Address - Phone:909-580-3353
Mailing Address - Fax:909-580-1363
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:DEPT SURGERY MODULAR # 3
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324
Practice Address - Country:US
Practice Address - Phone:909-580-3353
Practice Address - Fax:909-580-1363
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79166208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0079700Medicaid
CAZZZ13858ZMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
CAGR0079700Medicaid
CA00A791660Medicare PIN