Provider Demographics
NPI:1003095274
Name:R EDWARD MONTEJO MD PA
Entity Type:Organization
Organization Name:R EDWARD MONTEJO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARCY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTEJO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-467-0348
Mailing Address - Street 1:942 SEAWAY DR
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34949-3123
Mailing Address - Country:US
Mailing Address - Phone:772-467-0348
Mailing Address - Fax:772-466-8286
Practice Address - Street 1:942 SEAWAY DR
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34949-3123
Practice Address - Country:US
Practice Address - Phone:772-467-0348
Practice Address - Fax:772-466-8286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME557552084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273461300Medicaid
FL40258Medicare PIN