Provider Demographics
NPI:1932141934
Name:MONTANA, JOSEPH ANTHONY (OD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ANTHONY
Last Name:MONTANA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47303 DOVE CT
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-4835
Mailing Address - Country:US
Mailing Address - Phone:313-382-9650
Mailing Address - Fax:313-382-3428
Practice Address - Street 1:1755 DIX HWY
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-1412
Practice Address - Country:US
Practice Address - Phone:313-382-9650
Practice Address - Fax:313-382-3428
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002981152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI941785388Medicaid
MIU31887Medicare UPIN
MIH27940001Medicare ID - Type Unspecified