Provider Demographics
NPI:1417236803
Name:MONTGOMERY, AMANDA (OD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 COSHOCTON AVE # 3
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-1947
Mailing Address - Country:US
Mailing Address - Phone:740-326-1190
Mailing Address - Fax:740-326-9753
Practice Address - Street 1:812 COSHOCTON AVE # 3
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-1947
Practice Address - Country:US
Practice Address - Phone:740-326-1190
Practice Address - Fax:740-326-9753
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6058152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0112154Medicaid
OH1417236803OtherSUPERIOR VISION
OHCS1627100107OtherCARESOURCE
OH0112154Medicaid