Provider Demographics
NPI:1568527224
Name:MONTENEGRO, CARLOS H (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:H
Last Name:MONTENEGRO
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:PO BOX 94743
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91109-4743
Mailing Address - Country:US
Mailing Address - Phone:213-483-9996
Mailing Address - Fax:213-483-9831
Practice Address - Street 1:1800 W 6TH ST
Practice Address - Street 2:STE 3
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-3139
Practice Address - Country:US
Practice Address - Phone:213-483-9996
Practice Address - Fax:213-483-9831
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA048811173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A488111Medicaid
CA00A488111Medicaid