Provider Demographics
NPI:1760432462
Name:MONTGOMERY MEDICAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:MONTGOMERY MEDICAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANUSHIRAVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DADGAR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:301-279-2779
Mailing Address - Street 1:10110 MOLECULAR DRIVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-7542
Mailing Address - Country:US
Mailing Address - Phone:301-279-2779
Mailing Address - Fax:301-279-2767
Practice Address - Street 1:10110 MOLECULAR DRIVE
Practice Address - Street 2:SUITE 206
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-7542
Practice Address - Country:US
Practice Address - Phone:301-279-2779
Practice Address - Fax:301-279-2767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0067332174400000X
MDD0069766174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD404776100Medicaid
MD404776101Medicaid
DCG00650Medicare ID - Type UnspecifiedGROUP NUMBER