Provider Demographics
NPI:1689657934
Name:MONTGOMERY, BRUCE A (DO)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5757 MONCLOVA RD
Mailing Address - Street 2:STE 24
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1863
Mailing Address - Country:US
Mailing Address - Phone:419-897-2270
Mailing Address - Fax:419-897-2290
Practice Address - Street 1:5757 MONCLOVA RD
Practice Address - Street 2:STE 24
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1863
Practice Address - Country:US
Practice Address - Phone:419-897-2270
Practice Address - Fax:419-897-2290
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH34004231M207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000142183OtherANTHEM BCBS
OH02111OtherPARAMOUNT HEALTH CARE
OH0904927Medicaid
OH080155060OtherPALMETTO GBA RAILROAD MED
OH0904927Medicaid
OH0730896Medicare ID - Type Unspecified