Basic Information
| Provider Information | |||||||||
| NPI: | 1235115015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONGAR | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MONGAR | ||||||||
| OtherFirstName: | SAMANTHA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1081 N CHINA LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | RIDGECREST | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935553130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604993855 | ||||||||
| FaxNumber: | 7604993870 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 N CHINA LAKE BLVD | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | RIDGECREST | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935553131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604993855 | ||||||||
| FaxNumber: | 7604993870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 05/01/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 20A10029 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
No ID Information.