Provider Demographics
NPI:1730134198
Name:MONTGOMERY, THOMAS R (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:MONTGOMERY
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 79137
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0137
Mailing Address - Country:US
Mailing Address - Phone:757-668-7200
Mailing Address - Fax:757-668-9691
Practice Address - Street 1:601 CHILDRENS LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1910
Practice Address - Country:US
Practice Address - Phone:757-668-2840
Practice Address - Fax:757-668-2845
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035588208000000X, 2080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018739090001Medicaid
VA006722440Medicaid
MD130371600Medicaid
NC890534YMedicaid
NC890534YMedicaid
PA0018739090001Medicaid