Provider Demographics
NPI:1629024450
Name:MONTGOMERY, JOHN EDGAR LEE JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDGAR LEE
Last Name:MONTGOMERY
Suffix:JR
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 1:1799 CALLAWAY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:VA
Mailing Address - Zip Code:24151-5002
Mailing Address - Country:US
Mailing Address - Phone:540-489-3051
Mailing Address - Fax:
Practice Address - Street 1:180 FLOYD AVE
Practice Address - Street 2:EMERGENCY DEPT
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-1318
Practice Address - Country:US
Practice Address - Phone:540-483-5277
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101019310207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A72067Medicare UPIN