Provider Demographics
NPI:1477607091
Name:MONTEZ, JEREMY MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:MATTHEW
Last Name:MONTEZ
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:PO BOX 512185
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-0185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:412 W CARROLL AVE STE 200
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4709
Practice Address - Country:US
Practice Address - Phone:626-914-3921
Practice Address - Fax:626-914-9611
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA135818208800000X
CA19839363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes208800000XAllopathic & Osteopathic PhysiciansUrology