Provider Demographics
NPI:1699735159
Name:MONTGOMERY, STEPHEN (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
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 1:345 HIGHWAY 15 N
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-1105
Mailing Address - Country:US
Mailing Address - Phone:662-489-7430
Mailing Address - Fax:662-489-7938
Practice Address - Street 1:345 HIGHWAY 15 N
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-1105
Practice Address - Country:US
Practice Address - Phone:662-489-7430
Practice Address - Fax:662-489-7938
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114314Medicaid
MSB64406Medicare UPIN
MS00114314Medicaid