Provider Demographics
NPI:1316078868
Name:MICHAEL MONTGOMERY OD PC
Entity type:Organization
Organization Name:MICHAEL MONTGOMERY OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF OPTOMETRY
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:OD, PC
Authorized Official - Phone:417-532-2562
Mailing Address - Street 1:PO BOX 248
Mailing Address - Street 2:279 EAST ELM
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-0248
Mailing Address - Country:US
Mailing Address - Phone:417-532-2562
Mailing Address - Fax:417-592-2409
Practice Address - Street 1:279 E ELM
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536
Practice Address - Country:US
Practice Address - Phone:417-532-2562
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2552152W00000X, 332H00000X
MOTO2552207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO312368301Medicaid
MOT42763Medicare UPIN
MO312368301Medicaid
MO000007845Medicare UPIN