Provider Demographics
NPI:1386624526
Name:MONTGOMERY, RUSSELL SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:SCOTT
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 1:1211 W LA PALMA AVE
Mailing Address - Street 2:SUITE 505
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-2815
Mailing Address - Country:US
Mailing Address - Phone:714-778-1032
Mailing Address - Fax:714-778-5634
Practice Address - Street 1:1211 W LA PALMA AVE
Practice Address - Street 2:SUITE 505
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2815
Practice Address - Country:US
Practice Address - Phone:714-778-1032
Practice Address - Fax:714-778-5634
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81733174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARGR0093510Medicaid
AR00G817330Medicaid
ARGR0093510Medicaid
CAW15964Medicare ID - Type UnspecifiedGROUP NUMBER
AR00G817330Medicaid