Provider Demographics
NPI:1689618746
Name:MONTGOMERY, DIANA (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3905 SACRAMENTO ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-1636
Mailing Address - Country:US
Mailing Address - Phone:415-752-8038
Mailing Address - Fax:
Practice Address - Street 1:3905 SACRAMENTO ST
Practice Address - Street 2:SUITE 301
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-1636
Practice Address - Country:US
Practice Address - Phone:415-752-8038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88405208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A884050Medicaid
CA00A884050Medicaid
CA00A884050Medicare PIN