Provider Demographics
NPI:1427275098
Name:MONTGOMERY, WALTER DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:DAVID
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 1:2281 LINCOLN PARK RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:40069
Mailing Address - Country:US
Mailing Address - Phone:859-336-3941
Mailing Address - Fax:
Practice Address - Street 1:320 LORETTO RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033
Practice Address - Country:US
Practice Address - Phone:270-692-5180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31693207PH0002X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYG11374Medicare UPIN