Provider Demographics
NPI:1699300731
Name:MONTGOMERY, SIMONE NICOLE BOECKMANN (MD, MPH)
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:NICOLE BOECKMANN
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N STATE ST RM 3250
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-1001
Mailing Address - Country:US
Mailing Address - Phone:323-409-3360
Mailing Address - Fax:
Practice Address - Street 1:1200 N STATE STREET
Practice Address - Street 2:GENERAL HOSPITAL, DERMATOLOGY - RM 3250
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033
Practice Address - Country:US
Practice Address - Phone:323-409-3360
Practice Address - Fax:323-226-2654
Is Sole Proprietor?:No
Enumeration Date:2020-03-09
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA180644207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program