Provider Demographics
NPI:1295728293
Name:MONTGOMERY, BAXTER D (MD)
Entity type:Individual
Prefix:DR
First Name:BAXTER
Middle Name:D
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:PO BOX 20808
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77225-0808
Mailing Address - Country:US
Mailing Address - Phone:713-599-1144
Mailing Address - Fax:713-599-1199
Practice Address - Street 1:10480 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77025-5500
Practice Address - Country:US
Practice Address - Phone:713-599-1144
Practice Address - Fax:713-599-1199
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9549207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX081027701Medicaid
TX132190301Medicaid
TX5034595OtherAETNA
TX85680FOtherBLUE CROSS/BLUE SHIELD
TX10018324OtherAMERIGROUP
TX5034595OtherAETNA
TX081027701Medicaid
TX060052268Medicare PIN
TX0069BRMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
GA060052268Medicare PIN
TX132190301Medicaid