Provider Demographics
NPI:1124002969
Name:MONTGOMERY, MICHAEL R (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-3610
Mailing Address - Country:US
Mailing Address - Phone:417-532-2562
Mailing Address - Fax:417-532-2409
Practice Address - Street 1:279 E ELM ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-3610
Practice Address - Country:US
Practice Address - Phone:417-532-2562
Practice Address - Fax:417-532-2409
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02552152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
117102OtherBCBC-LEBABON LOCATION
117105OtherBCBS
12603OtherSPECTERA-LEBANON LOCATION
MO312368319Medicaid
12603OtherSPECTERA-LEBANON LOCATION
MO070425320Medicare PIN
MO0505630001Medicare NSC