Provider Demographics
NPI:1366553166
Name:MONTGOMERY, MICHAEL T (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
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:HC 77 BOX 14A
Mailing Address - Street 2:
Mailing Address - City:HINTON
Mailing Address - State:WV
Mailing Address - Zip Code:25951-9601
Mailing Address - Country:US
Mailing Address - Phone:304-466-2783
Mailing Address - Fax:304-423-5185
Practice Address - Street 1:469 EMILY DR
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-5512
Practice Address - Country:US
Practice Address - Phone:304-423-5180
Practice Address - Fax:304-423-5185
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1486207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVG08803Medicare UPIN
WVMO0836616Medicare ID - Type Unspecified