Provider Demographics
NPI:1336883917
Name:MONGE, MICHAEL JESSE (RT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JESSE
Last Name:MONGE
Suffix:
Gender:M
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6522 BUFFALO AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY GLEN
Mailing Address - State:CA
Mailing Address - Zip Code:91401-1703
Mailing Address - Country:US
Mailing Address - Phone:818-271-4285
Mailing Address - Fax:
Practice Address - Street 1:6522 BUFFALO AVE
Practice Address - Street 2:
Practice Address - City:VALLEY GLEN
Practice Address - State:CA
Practice Address - Zip Code:91401-1703
Practice Address - Country:US
Practice Address - Phone:818-271-4285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHF001086342085R0202X, 247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology