Provider Demographics
NPI:1245321165
Name:MONTELONGO, FERNANDO A (MD)
Entity type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:A
Last Name:MONTELONGO
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 1:932 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-2109
Mailing Address - Country:US
Mailing Address - Phone:714-997-8050
Mailing Address - Fax:714-997-5075
Practice Address - Street 1:932 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-2109
Practice Address - Country:US
Practice Address - Phone:714-997-8050
Practice Address - Fax:714-997-5075
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45460174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92580Medicare UPIN