Provider Demographics
NPI:1902048234
Name:MONTGOMERY, VERNESHA (MD)
Entity type:Individual
Prefix:
First Name:VERNESHA
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 LINCOLN PARK BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-6404
Mailing Address - Country:US
Mailing Address - Phone:937-294-4487
Mailing Address - Fax:937-294-2255
Practice Address - Street 1:311 W. FAIRCHILD ST.
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832
Practice Address - Country:US
Practice Address - Phone:217-431-7650
Practice Address - Fax:217-431-7792
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO49452207Q00000X
IL036134565207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO34887709Medicaid