Provider Demographics
NPI:1326030099
Name:MONTAGUE, LAURIE (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:MONTAGUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9064 NW 13TH TER
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-2907
Mailing Address - Country:US
Mailing Address - Phone:305-392-8084
Mailing Address - Fax:
Practice Address - Street 1:14100 58TH ST N STE 100
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-9900
Practice Address - Country:US
Practice Address - Phone:727-824-8181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042.0013060207Q00000X
FLME163663207Q00000X
NH10816207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH2861860OtherCIGNA
VT1013829Medicaid
FL120341500Medicaid
NH30206983Medicaid
NH01YP12315NH01OtherANTHEM