Provider Demographics
NPI:1093717159
Name:MONTGOMERY, C. TED (MD)
Entity Type:Individual
Prefix:DR
First Name:C.
Middle Name:TED
Last Name:MONTGOMERY
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 1:915 W MONROE ST
Mailing Address - Street 2:STE 200
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-1177
Mailing Address - Country:US
Mailing Address - Phone:904-384-2240
Mailing Address - Fax:904-448-0030
Practice Address - Street 1:3550 UNIVERSITY BLVD S
Practice Address - Street 2:STE 301
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4225
Practice Address - Country:US
Practice Address - Phone:904-384-2240
Practice Address - Fax:904-448-0030
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME10755174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371200100Medicaid
FLD52938Medicare UPIN
FL371200100Medicaid