Provider Demographics
NPI:1992773501
Name:MONTGOMERY, DAVID (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:320 E 8TH ST STE 141
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3382
Practice Address - Country:US
Practice Address - Phone:740-374-5580
Practice Address - Fax:740-374-6266
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007570207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1803870000Medicaid
OH2229234Medicaid
WV1803870000Medicaid
H34157Medicare UPIN
OH4045993Medicare ID - Type Unspecified
OH4045992Medicare PIN
OH4045994Medicare PIN
WV1803870000Medicaid