Provider Demographics
NPI:1043973340
Name:MONTAGUE, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:MONTAGUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1280 BRAMLETT BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-2362
Mailing Address - Country:US
Mailing Address - Phone:470-484-0932
Mailing Address - Fax:
Practice Address - Street 1:1280 BRAMLETT BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-2362
Practice Address - Country:US
Practice Address - Phone:470-484-0932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3320622085D0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging