Provider Demographics
NPI:1609836782
Name:MONTGOMERY, JOHN ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ALAN
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 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:800-883-7243
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:3300 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-3120
Practice Address - Country:US
Practice Address - Phone:707-725-3361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG19237208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G192370Medicaid
CAA40575Medicare UPIN
CA00G192370Medicare PIN
CA00G192370Medicaid