Provider Demographics
NPI:1588310734
Name:MONTENEGRO, MARLON JOSE (CSFA)
Entity type:Individual
Prefix:
First Name:MARLON
Middle Name:JOSE
Last Name:MONTENEGRO
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8338 WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-3982
Mailing Address - Country:US
Mailing Address - Phone:138-630-2394
Mailing Address - Fax:
Practice Address - Street 1:2125 STATE ST STE 6
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4972
Practice Address - Country:US
Practice Address - Phone:812-948-7417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20-391208600000X
WI20-931208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery