Provider Demographics
NPI:1659545713
Name:MONTEJO, MICHAEL EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:MONTEJO
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 1031
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32802-1031
Mailing Address - Country:US
Mailing Address - Phone:407-872-7786
Mailing Address - Fax:407-872-3630
Practice Address - Street 1:2501 N ORANGE AVE
Practice Address - Street 2:SUITE 181
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4603
Practice Address - Country:US
Practice Address - Phone:407-303-2030
Practice Address - Fax:407-303-2040
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6894390-12052085R0001X
FLME1098922085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFE594OtherMEDICARE
FL3667100Medicaid