Provider Demographics
NPI:1154323731
Name:MONTGOMERY, TRAVIS J (DPM)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:J
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:DPM
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3731 GUION ROAD
Mailing Address - Street 2:SUITE C
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-7604
Mailing Address - Country:US
Mailing Address - Phone:317-931-0664
Mailing Address - Fax:317-927-0924
Practice Address - Street 1:3731 GUION ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-7604
Practice Address - Country:US
Practice Address - Phone:317-931-0664
Practice Address - Fax:317-927-0924
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001006A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200525150Medicaid
IN192530QMedicare PIN
IN200525150Medicaid
INV05927Medicare UPIN
INP00265351Medicare PIN