Provider Demographics
NPI:1194739557
Name:MONTGOMERY, JOEL DAVID (MPT)
Entity type:Individual
Prefix:MR
First Name:JOEL
Middle Name:DAVID
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2714 W OXFORD LOOP
Mailing Address - Street 2:SUITE 164
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5711
Mailing Address - Country:US
Mailing Address - Phone:662-232-8949
Mailing Address - Fax:662-232-8950
Practice Address - Street 1:2714 W OXFORD LOOP
Practice Address - Street 2:SUITE 164
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5711
Practice Address - Country:US
Practice Address - Phone:662-232-8949
Practice Address - Fax:662-232-8950
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3054225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
256594Medicare ID - Type Unspecified