Provider Demographics
NPI:1316948656
Name:MONTAGUE, MICHAEL T (PAC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:MONTAGUE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 N LANSING AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74106-5907
Mailing Address - Country:US
Mailing Address - Phone:918-587-2171
Mailing Address - Fax:918-295-6155
Practice Address - Street 1:1334 N LANSING AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-5907
Practice Address - Country:US
Practice Address - Phone:918-587-2171
Practice Address - Fax:918-295-6155
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1208207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK37-1803OtherMEDICARE
OK100768880FMedicaid
OK100768880IMedicaid
OK100768880JMedicaid
OK37-1832OtherMEDICARE
OK37-1834OtherMEDICARE
OK100031840AMedicaid
OK37-1832OtherMEDICARE
OK37-1834OtherMEDICARE