Provider Demographics
NPI:1164853453
Name:MONTGOMERY, ROBERT SR
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:MONTGOMERY
Suffix:SR
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 1:513 GASLIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3127
Mailing Address - Country:US
Mailing Address - Phone:936-238-3629
Mailing Address - Fax:936-238-3769
Practice Address - Street 1:513 GASLIGHT BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3127
Practice Address - Country:US
Practice Address - Phone:936-238-3629
Practice Address - Fax:936-238-3769
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDR4127156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician