Provider Demographics
NPI:1457300956
Name:MONTGOMERY, MATTHEW THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:MONTGOMERY
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 1:600 PETER JEFFERSON PKWY
Mailing Address - Street 2:STE 290
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911
Mailing Address - Country:US
Mailing Address - Phone:434-977-4488
Mailing Address - Fax:434-977-6103
Practice Address - Street 1:600 PETER JEFFERSON PKWY
Practice Address - Street 2:STE 290
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911
Practice Address - Country:US
Practice Address - Phone:434-977-4488
Practice Address - Fax:434-977-6103
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045889207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6204538Medicaid
160000674Medicare ID - Type Unspecified
E66430Medicare UPIN