Provider Demographics
NPI:1417162314
Name:NATIVIDAD, MONA LISA SANTOS (MD)
Entity Type:Individual
Prefix:DR
First Name:MONA LISA
Middle Name:SANTOS
Last Name:NATIVIDAD
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 1:1629 GENESEE ST
Mailing Address - Street 2:APT. A-50
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-4747
Mailing Address - Country:US
Mailing Address - Phone:315-790-8499
Mailing Address - Fax:
Practice Address - Street 1:3700 VACA VALLEY PKWY
Practice Address - Street 2:ADULT MEDICINE DEPARTMENT
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-9430
Practice Address - Country:US
Practice Address - Phone:707-453-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 99973207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine