Provider Demographics
NPI:1487673208
Name:MONTANO, CHARLES BRENDAN (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRENDAN
Last Name:MONTANO
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 1:160 WEST ST
Mailing Address - Street 2:BUILDING 1 SUITE A
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-2441
Mailing Address - Country:US
Mailing Address - Phone:860-632-0144
Mailing Address - Fax:860-632-7882
Practice Address - Street 1:160 WEST ST
Practice Address - Street 2:BUILDING 1 SUITE A
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-2441
Practice Address - Country:US
Practice Address - Phone:860-632-0144
Practice Address - Fax:860-632-7882
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016871207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT110000734Medicare ID - Type Unspecified
CTB84467Medicare UPIN