Provider Demographics
NPI:1437291226
Name:MONTGOMERY, DOUGLAS J (PA-C)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 WILLIAM HOWARD TAFT, PHYS DIV
Mailing Address - Street 2:2ND FL, CBO2-3, ATTN: CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2906
Mailing Address - Country:US
Mailing Address - Phone:513-792-7445
Mailing Address - Fax:513-791-4042
Practice Address - Street 1:9250 BLUE ASH RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-6822
Practice Address - Country:US
Practice Address - Phone:513-792-7445
Practice Address - Fax:513-791-4042
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.000196363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1630393OtherGATEWAY HEALTH
OHP10000897204OtherBUCKEYE
OH752112OtherWELLCARE
OH0077329OtherMEDICAID
OH272352575063OtherCARESOURCE
OH5188071OtherAETNA
OH791940OtherANTHEM
OHH155980OtherMEDICARE
KYK052931OtherMEDICARE
OHP01191326OtherRAILROAD MEDICARE
KYP01252598OtherRAILROAD MEDICARE