Provider Demographics
NPI:1043222508
Name:MONTEYNE, PETER J (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:MONTEYNE
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:P.O. BOX 1499
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70707-1499
Mailing Address - Country:US
Mailing Address - Phone:225-647-6533
Mailing Address - Fax:225-644-7533
Practice Address - Street 1:2304 S. BURNSIDE AVE
Practice Address - Street 2:STE 2
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737
Practice Address - Country:US
Practice Address - Phone:225-647-6533
Practice Address - Fax:225-644-7533
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08055R208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1386952Medicaid
LA08055ROtherLA STATE MEDICAL LICENSE
LA19208OtherLA CONTROLLED SUBSTANCE N
AM1770331OtherDEA NUMBER
55858Medicare ID - Type UnspecifiedMEDICARE
LA1386952Medicaid