Provider Demographics
NPI:1285823500
Name:MONTESA, DAISY GONZALES
Entity Type:Individual
Prefix:
First Name:DAISY
Middle Name:GONZALES
Last Name:MONTESA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2417
Mailing Address - Country:US
Mailing Address - Phone:650-585-4495
Mailing Address - Fax:
Practice Address - Street 1:129 16TH AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2417
Practice Address - Country:US
Practice Address - Phone:650-585-4495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58614183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist