Provider Demographics
NPI:1356677116
Name:MONTANA, PETER J
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:MONTANA
Suffix:
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 1:1421 COURTYARD DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95118-1936
Mailing Address - Country:US
Mailing Address - Phone:408-445-8485
Mailing Address - Fax:408-705-2129
Practice Address - Street 1:1421 COURTYARD DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95118-1936
Practice Address - Country:US
Practice Address - Phone:408-445-8485
Practice Address - Fax:408-705-2129
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA167764405332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier