Provider Demographics
NPI:1023018629
Name:KATHLEEN R. MONTEMAYOR, M. D., FAAP
Entity Type:Organization
Organization Name:KATHLEEN R. MONTEMAYOR, M. D., FAAP
Other - Org Name:RIVER'S EDGE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MONTEMAYOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-844-3551
Mailing Address - Street 1:6352 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-2241
Mailing Address - Country:US
Mailing Address - Phone:727-844-3551
Mailing Address - Fax:727-847-0427
Practice Address - Street 1:6352 RIVER RD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-2241
Practice Address - Country:US
Practice Address - Phone:727-844-3551
Practice Address - Fax:727-847-0427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268389000Medicaid
FL34914OtherBLUE CROSS BLUE SHIELD