Provider Demographics
NPI:1033503255
Name:MONTAG, NATHANIEL (DO)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:MONTAG
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 1:355 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-2207
Mailing Address - Country:US
Mailing Address - Phone:317-963-7077
Mailing Address - Fax:
Practice Address - Street 1:500 GRAND AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4967
Practice Address - Country:US
Practice Address - Phone:201-567-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY296383-1208100000X
IN02005347A208100000X
390200000X
NJ25MB10420400208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program