Provider Demographics
NPI:1861481731
Name:SNOW, MONTY D (MD)
Entity Type:Individual
Prefix:
First Name:MONTY
Middle Name:D
Last Name:SNOW
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 1:1125 E SOUTHERN AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-5045
Mailing Address - Country:US
Mailing Address - Phone:480-545-8119
Mailing Address - Fax:480-892-6805
Practice Address - Street 1:1125 E SOUTHERN AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5045
Practice Address - Country:US
Practice Address - Phone:480-545-8119
Practice Address - Fax:480-892-6805
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ244822085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ418550Medicaid
AZZ123762OtherMEDICARE ID EVAC
F76298Medicare UPIN
21602Medicare ID - Type UnspecifiedEVDI
AZ418550Medicaid
61705Medicare ID - Type UnspecifiedDOMRI