Provider Demographics
NPI:1780209049
Name:MONTENEGRO, DANNY JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:DANNY
Middle Name:JONATHAN
Last Name:MONTENEGRO
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 1:404 ARROWHEAD TRL
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-6592
Mailing Address - Country:US
Mailing Address - Phone:678-577-1429
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST # HB-4000
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-3159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11986OtherRESIDENCY TRAINING PERMIT