Provider Demographics
NPI:1033170667
Name:MONTGOMERY, RANDY JOE (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:JOE
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 1:4825 CAMP BOWIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-4150
Mailing Address - Country:US
Mailing Address - Phone:817-336-2010
Mailing Address - Fax:817-377-0074
Practice Address - Street 1:4825 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-4150
Practice Address - Country:US
Practice Address - Phone:817-336-2010
Practice Address - Fax:817-377-0074
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH1000207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E06981Medicare UPIN
00B72UMedicare PIN