Provider Demographics
NPI:1225133499
Name:MONTGOMERY, DERRICK ALAN (MD)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:ALAN
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316TH MDG
Mailing Address - Street 2:1060 W. PERIMETER RD SUITE 3K43
Mailing Address - City:ANDREWS AFB
Mailing Address - State:MD
Mailing Address - Zip Code:20762
Mailing Address - Country:US
Mailing Address - Phone:240-612-1730
Mailing Address - Fax:
Practice Address - Street 1:316TH MDG
Practice Address - Street 2:1060 W. PERIMETER RD SUITE 3K43
Practice Address - City:ANDREWS AFB
Practice Address - State:MD
Practice Address - Zip Code:20762
Practice Address - Country:US
Practice Address - Phone:240-612-1730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96117207W00000X
OH35.125039207WX0107X, 207WX0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist