Provider Demographics
NPI:1861459661
Name:MONTGOMERY, DANIELE J (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIELE
Middle Name:J
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 1:7015 AC SKINNER PARKWAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-363-2113
Mailing Address - Fax:904-363-2606
Practice Address - Street 1:9 SAN BARTOLA DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5767
Practice Address - Country:US
Practice Address - Phone:904-825-4500
Practice Address - Fax:904-825-3672
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 66664207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL25632SOtherMEDICARE
FL25632OtherBCBS
FL024339200Medicaid
FL25632OtherBCBS
FL25632UMedicare PIN
FL25632OtherBCBS
FL201080OtherAVMED
FLF87802Medicare UPIN
FL379754600Medicaid