Provider Demographics
NPI:1588613103
Name:MONTENEGRO, CARLOS E (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:E
Last Name:MONTENEGRO
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 1289
Mailing Address - Street 2:
Mailing Address - City:VARNVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29944
Mailing Address - Country:US
Mailing Address - Phone:803-943-4003
Mailing Address - Fax:803-943-4701
Practice Address - Street 1:408 JACKSON AVE E
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:SC
Practice Address - Zip Code:29924
Practice Address - Country:US
Practice Address - Phone:803-943-4003
Practice Address - Fax:803-943-4701
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23479208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00166936OtherRAILROAD MEDICARE
SCP00166936OtherRAILROAD MEDI CARE
SC234797Medicaid
SCP00166936OtherRAILROAD MEDICARE
SCP00166936OtherRAILROAD MEDI CARE