Provider Demographics
NPI:1871637678
Name:MONTGOMERY, LORETTA (MD)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LORETTA
Other - Middle Name:
Other - Last Name:MONTGOMERY BOARDMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4900 S MONACO ST
Mailing Address - Street 2:STE 210
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3486
Mailing Address - Country:US
Mailing Address - Phone:720-979-0836
Mailing Address - Fax:303-369-1919
Practice Address - Street 1:1400 S POTOMAC ST
Practice Address - Street 2:#190
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-4528
Practice Address - Country:US
Practice Address - Phone:720-979-0836
Practice Address - Fax:303-369-1919
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO19038062Medicaid
CO276543YL7XMedicare PIN
COE98725Medicare UPIN
CO19038062Medicaid