Provider Demographics
NPI:1740242437
Name:MONTAZEM, ANDRE H (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:H
Last Name:MONTAZEM
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 1:54 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07506-1539
Mailing Address - Country:US
Mailing Address - Phone:862-684-5578
Mailing Address - Fax:
Practice Address - Street 1:1 GUSTAVE L LEVY PL
Practice Address - Street 2:BOX 1187
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6500
Practice Address - Country:US
Practice Address - Phone:212-241-0316
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208721204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01795293Medicaid
NYD11441Medicare ID - Type Unspecified
NY01795293Medicaid