Provider Demographics
NPI:1083699128
Name:MONTEZON, LOURDES LLOREN (MD)
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:LLOREN
Last Name:MONTEZON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 ANTHONY RD
Mailing Address - Street 2:
Mailing Address - City:GLEN GARDNER
Mailing Address - State:NJ
Mailing Address - Zip Code:08826-3052
Mailing Address - Country:US
Mailing Address - Phone:908-832-6512
Mailing Address - Fax:
Practice Address - Street 1:492 ROUTE 57 W
Practice Address - Street 2:FX ANIDOME CTR
Practice Address - City:WASHINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07882-4338
Practice Address - Country:US
Practice Address - Phone:908-689-1000
Practice Address - Fax:908-689-4529
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA508372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ598425C2FOtherMEDICARE BILLING NO
NJ3735800Medicaid
NJ2320853000OtherAMERI HEALTH
NJ598425Medicare ID - Type Unspecified
NJ3735800Medicaid