Provider Demographics
NPI:1114995602
Name:MONTGOMERY, TAMARA MARIE (DO)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:MARIE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:320 E. EIGHTH ST.
Practice Address - Street 2:SUITE 141
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1656
Practice Address - Country:US
Practice Address - Phone:740-374-5580
Practice Address - Fax:740-374-6266
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-7567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2002638000Medicaid
OH2229243Medicaid
OH000000678799OtherANTHEM
OH2229243Medicaid
WV2002638000Medicaid
OH2229243Medicaid
OH4046245Medicare PIN
OH4046244Medicare ID - Type Unspecified