Provider Demographics
NPI:1326003674
Name:MONTAQUILA, STEPHEN M (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:M
Last Name:MONTAQUILA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02888-3855
Mailing Address - Country:US
Mailing Address - Phone:401-732-2350
Mailing Address - Fax:401-738-2744
Practice Address - Street 1:222 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-3855
Practice Address - Country:US
Practice Address - Phone:401-732-2350
Practice Address - Fax:401-738-2744
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTG00460152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI400433OtherBLUE CHIP
RIAA47839OtherHARVARD PILGRIM HEALTH
RI7251720OtherCIGNA
RI2281709OtherFIRST HEALTH
RIU55309Medicare UPIN