Provider Demographics
NPI:1114223617
Name:MONTAGUE BLUNDON, III, MD, PA
Entity type:Organization
Organization Name:MONTAGUE BLUNDON, III, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MONTAGUE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUNDON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:301-897-5505
Mailing Address - Street 1:5640 SHIELDS DR
Mailing Address - Street 2:WYNGATE MEDICAL PARK
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-3573
Mailing Address - Country:US
Mailing Address - Phone:301-897-5505
Mailing Address - Fax:301-897-0887
Practice Address - Street 1:5640 SHIELDS DR
Practice Address - Street 2:WYNGATE MEDICAL PARK
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-3573
Practice Address - Country:US
Practice Address - Phone:307-897-5505
Practice Address - Fax:301-897-0887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-31
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0025637207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD266081400Medicaid
MD266081400Medicaid