Provider Demographics
NPI:1437104544
Name:MONTALBANO, MICHELLE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:MONTALBANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:MONTELBANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2430 NW MYHRE RD
Mailing Address - Street 2:STE 101
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7669
Mailing Address - Country:US
Mailing Address - Phone:360-337-1177
Mailing Address - Fax:360-337-1170
Practice Address - Street 1:2430 NW MYHRE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7669
Practice Address - Country:US
Practice Address - Phone:360-337-1177
Practice Address - Fax:360-337-1170
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00045790207K00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
7691645OtherAETNA
WA8454597Medicaid
WA1156MOOtherREGENCE BLUE SHIELD
WA205756OtherLABOR & INDUSTRIES
WA205756OtherLABOR & INDUSTRIES
7691645OtherAETNA
WA205756OtherLABOR & INDUSTRIES
G8878723Medicare PIN
G8873847Medicare PIN
WA8454597Medicaid
WA1156MOOtherREGENCE BLUE SHIELD