Provider Demographics
NPI:1245212505
Name:TOLENTINO, MILAGROS (MD)
Entity Type:Individual
Prefix:DR
First Name:MILAGROS
Middle Name:
Last Name:TOLENTINO
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 1350
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-1350
Mailing Address - Country:US
Mailing Address - Phone:707-994-9469
Mailing Address - Fax:707-994-8758
Practice Address - Street 1:15666 18TH AVE
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422
Practice Address - Country:US
Practice Address - Phone:707-994-9469
Practice Address - Fax:707-994-8758
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31830207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA31830OtherBLUE CROSS OF CALIFORNIA
CA00A318300OtherBLUE SHIELD OF CALIFORNIA
CA00A318300Medicaid
CA00A318300OtherBLUE SHIELD OF CALIFORNIA
CAC03902Medicare UPIN