Provider Demographics
NPI:1255316931
Name:MONTIJO, SANDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:MONTIJO
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 1:210 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:KING CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93930-3432
Mailing Address - Country:US
Mailing Address - Phone:831-385-5471
Mailing Address - Fax:831-385-5940
Practice Address - Street 1:210 CANAL ST
Practice Address - Street 2:
Practice Address - City:KING CITY
Practice Address - State:CA
Practice Address - Zip Code:93930-3432
Practice Address - Country:US
Practice Address - Phone:831-385-5471
Practice Address - Fax:831-385-5940
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60155208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG610551Medicaid
CAG610551Medicaid
CA00G610551Medicare ID - Type Unspecified