Provider Demographics
NPI:1982629853
Name:DANIEL O. MONGIANO, MD, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DANIEL O. MONGIANO, MD, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:AV OCCUPATIONAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAHLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-951-9195
Mailing Address - Street 1:42220 10TH ST W
Mailing Address - Street 2:STE 109
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-7075
Mailing Address - Country:US
Mailing Address - Phone:661-951-9195
Mailing Address - Fax:
Practice Address - Street 1:42220 10TH ST W
Practice Address - Street 2:STE 109
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-7075
Practice Address - Country:US
Practice Address - Phone:661-951-9195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54903207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A549030Medicaid
CAEB750AMedicare UPIN
CA00A549030Medicaid
CAEB750AMedicare PIN
CAA54903Medicare PIN