Provider Demographics
NPI:1639580004
Name:MONTGOMERY, ROSS (OD)
Entity Type:Individual
Prefix:MR
First Name:ROSS
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-1948
Mailing Address - Country:US
Mailing Address - Phone:770-254-0200
Mailing Address - Fax:
Practice Address - Street 1:1105 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-2905
Practice Address - Country:US
Practice Address - Phone:478-987-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-19
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002776152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist