Provider Demographics
NPI:1417419078
Name:ALVARENGA MONTOYA, JORGE DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:DAVID
Last Name:ALVARENGA MONTOYA
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 1:750 E ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:436 HINSDALE RD
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-1648
Practice Address - Country:US
Practice Address - Phone:315-488-0996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY319369207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program