Provider Demographics
NPI:1932145067
Name:MONTGOMERY, GRETCHEN SUZANNE (MD)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:SUZANNE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:
Other - Last Name:WILLOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:516 TWIN CEDARS DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7288
Mailing Address - Country:US
Mailing Address - Phone:601-278-3269
Mailing Address - Fax:
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:601-200-6175
Practice Address - Fax:601-200-2020
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC175540207P00000X
MS18545207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05957798Medicaid
MS930003266Medicare ID - Type Unspecified
MS05957798Medicaid