Provider Demographics
NPI:1821089400
Name:MONTGOMERY, SARA L (MD)
Entity Type:Individual
Prefix:DR
First Name:SARA
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 1:108 N BEHREND AVE STE A
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8418
Mailing Address - Country:US
Mailing Address - Phone:505-716-2842
Mailing Address - Fax:
Practice Address - Street 1:108 N BEHREND AVE STE A
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8418
Practice Address - Country:US
Practice Address - Phone:505-716-2842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD200500502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM80456057Medicaid
AZ945636Medicaid
CO82679771Medicaid
320059Medicare Oscar/Certification
NM80456057Medicaid
I27692Medicare UPIN