Provider Demographics
NPI:1922100080
Name:MONTGOMERY, DAN G (MD)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:G
Last Name:MONTGOMERY
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 1:830 MEDICAL CT E
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-4612
Mailing Address - Country:US
Mailing Address - Phone:352-726-6633
Mailing Address - Fax:352-726-9763
Practice Address - Street 1:830 MEDICAL CT E
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4612
Practice Address - Country:US
Practice Address - Phone:352-726-6633
Practice Address - Fax:352-726-9763
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0042680207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04198OtherBCBS
FL046865700Medicaid
FL046865700Medicaid