Provider Demographics
NPI:1760431019
Name:MONTGOMERY, JEFFREY (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:MONTGOMERY
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 1:211 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6220
Mailing Address - Country:US
Mailing Address - Phone:618-462-9818
Mailing Address - Fax:800-432-6004
Practice Address - Street 1:162 THF BLVD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1141
Practice Address - Country:US
Practice Address - Phone:636-537-0700
Practice Address - Fax:636-536-2066
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008990152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00218689OtherRAILROAD MEDICARE
ILK18248Medicare PIN
ILP00218689OtherRAILROAD MEDICARE