Provider Demographics
NPI:1699795815
Name:MONTGOMERY, LARRY LEE (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:LEE
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LEE
Other - Middle Name:
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1514 JEFFERSON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:8342 PERKINS RD
Practice Address - Street 2:SUITE M
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-1084
Practice Address - Country:US
Practice Address - Phone:225-218-4044
Practice Address - Fax:225-308-4309
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16277207Q00000X
LAMD.202410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS16277OtherSTATE MEDICAL LICENSE
LACDS.036229-MDOtherSTATE BOARD OF PHARMACY
MS00120513Medicaid
LA4N865DX98OtherMEDICARE MEMBER PTAN
LA1375063Medicaid
LAMD.202410OtherSTATE LICENSE
LAMD.202410OtherSTATE LICENSE
MSG64961Medicare UPIN
LA1375063Medicaid