Provider Demographics
NPI:1407800543
Name:MONTALBO, MARIONITO N (MD)
Entity Type:Individual
Prefix:
First Name:MARIONITO
Middle Name:N
Last Name:MONTALBO
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 1:42 NICHOLS ST STE 10
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559-2196
Mailing Address - Country:US
Mailing Address - Phone:585-637-7558
Mailing Address - Fax:585-637-7566
Practice Address - Street 1:42 NICHOLS ST STE 10
Practice Address - Street 2:
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-2196
Practice Address - Country:US
Practice Address - Phone:585-637-7558
Practice Address - Fax:585-637-7566
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302489207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05953186Medicaid
WI1407800543Medicaid
F83249Medicare UPIN
WI0357 68-086Medicare PIN
0018D73601Medicare ID - Type Unspecified