Provider Demographics
NPI:1366415721
Name:MONTANEZ, EDWARD P (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:P
Last Name:MONTANEZ
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 1:1908 N 203RD ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-2889
Mailing Address - Country:US
Mailing Address - Phone:402-289-4031
Mailing Address - Fax:402-289-3185
Practice Address - Street 1:1908 N 203RD ST
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-2889
Practice Address - Country:US
Practice Address - Phone:402-289-4031
Practice Address - Fax:402-289-3185
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17355207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE17355OtherLICENSE
IA0949099OtherMEDIPASS
1366415721OtherNPI
NE470710146-13Medicaid
AM3208039OtherDEA #
089083MOMedicare ID - Type Unspecified
IA0949099OtherMEDIPASS