Provider Demographics
NPI:1043294713
Name:MONTAGUE, DAVID L (MD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:L
Last Name:MONTAGUE
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 1:7130 GLEN FOREST DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3754
Mailing Address - Country:US
Mailing Address - Phone:804-288-4084
Mailing Address - Fax:804-282-8678
Practice Address - Street 1:7130 GLEN FOREST DR
Practice Address - Street 2:SUITE 101
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-3754
Practice Address - Country:US
Practice Address - Phone:804-288-4084
Practice Address - Fax:804-282-8678
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101028411174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA160001697Medicare ID - Type Unspecified
B09049Medicare UPIN