Provider Demographics
NPI:1760467344
Name:MONTGOMERY, LESLIE L (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:L
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 DIAMOND HILL RD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07922-2104
Mailing Address - Country:US
Mailing Address - Phone:908-273-4300
Mailing Address - Fax:
Practice Address - Street 1:1255 BROAD ST
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3398
Practice Address - Country:US
Practice Address - Phone:973-327-9584
Practice Address - Fax:833-578-2190
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190436208600000X
NJ25MA09747000208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
75L211Medicare ID - Type Unspecified
G43963Medicare UPIN