Provider Demographics
NPI:1902007990
Name:MONTGOMERY, JEFFREY MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-1061
Mailing Address - Country:US
Mailing Address - Phone:570-586-1134
Mailing Address - Fax:570-586-1136
Practice Address - Street 1:407 N STATE ST
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-1061
Practice Address - Country:US
Practice Address - Phone:570-586-1134
Practice Address - Fax:570-586-1136
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2021-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014541207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102210583Medicaid
PA133267Medicare PIN