Provider Demographics
NPI:1417984782
Name:MONTANA, JOSEPHINE BAISA (MD)
Entity Type:Individual
Prefix:MRS
First Name:JOSEPHINE
Middle Name:BAISA
Last Name:MONTANA
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 1:15995 TUSCOLARD SUTIE 202
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307
Mailing Address - Country:US
Mailing Address - Phone:760-242-5111
Mailing Address - Fax:760-418-6486
Practice Address - Street 1:15995 TUSCOLA RD SUITE 202
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307
Practice Address - Country:US
Practice Address - Phone:760-242-5111
Practice Address - Fax:760-242-5199
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC54399207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC54399OtherCA STATE LICENSE
CAC54399OtherCA STATE LICENSE
CAEJ644TMedicare UPIN
NJA62577Medicare UPIN
CAEJ644YMedicare UPIN
CAEJ644XMedicare UPIN
CAEJ644UMedicare UPIN
CAEJ644WMedicare UPIN
CAEJ644TMedicare UPIN