Provider Demographics
NPI:1235234469
Name:OMOHUNDRO, LUKE WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:WILLIAM
Last Name:OMOHUNDRO
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 1:935 HIGHLAND BLVD STE 2200
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6915
Mailing Address - Country:US
Mailing Address - Phone:406-414-5700
Mailing Address - Fax:406-414-4768
Practice Address - Street 1:935 HIGHLAND BLVD STE 2200
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6915
Practice Address - Country:US
Practice Address - Phone:406-414-5700
Practice Address - Fax:406-414-4768
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9550207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0026605Medicaid
MT080160674OtherRAILROAD MEDICARE
MT000081601Medicare PIN
MT080160674OtherRAILROAD MEDICARE