Provider Demographics
NPI:1710079793
Name:MONTELLA, ANTHONY (OD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:MONTELLA
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 1:15324 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-1012
Mailing Address - Country:US
Mailing Address - Phone:586-777-9100
Mailing Address - Fax:586-777-9100
Practice Address - Street 1:15324 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-1012
Practice Address - Country:US
Practice Address - Phone:586-777-9100
Practice Address - Fax:586-777-9100
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2013-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002464152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5089743Medicaid
OE06847OtherBLUE CROSS OF MICH
156260001OtherDME MEDICARE
156260001OtherDME MEDICARE
OE06847OtherBLUE CROSS OF MICH
MI5089743Medicaid