Provider Demographics
NPI:1760519227
Name:MONTGOMERY, STEPHEN W (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:W
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 1:101 N MISSOURI AVENUE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-4657
Mailing Address - Country:US
Mailing Address - Phone:505-623-8420
Mailing Address - Fax:
Practice Address - Street 1:101 N MISSOURI AVENUE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-4657
Practice Address - Country:US
Practice Address - Phone:505-623-8420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM79230207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM11189Medicaid
NM00NM001943OtherBCBS
NM11189Medicaid
NM00NM001943OtherBCBS