Provider Demographics
NPI:1073358636
Name:MONTGOMERY, MARK (MPA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-1915
Mailing Address - Country:US
Mailing Address - Phone:541-942-2217
Mailing Address - Fax:
Practice Address - Street 1:1115 W MAIN ST
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-1915
Practice Address - Country:US
Practice Address - Phone:541-942-2217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist