Provider Demographics
NPI:1124768783
Name:MONTGOMERY, ERIC Y
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:Y
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 CLARK ST APT 317
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-2454
Mailing Address - Country:US
Mailing Address - Phone:630-901-2280
Mailing Address - Fax:
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7201
Practice Address - Country:US
Practice Address - Phone:630-901-2280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program