Provider Demographics
NPI:1184692238
Name:MONTAZEMI, ROBERT KOMRON (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:KOMRON
Last Name:MONTAZEMI
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 1:1300 MICCOSUKEE RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5054
Mailing Address - Country:US
Mailing Address - Phone:850-431-4556
Mailing Address - Fax:
Practice Address - Street 1:1300 MICCOSUKEE RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5054
Practice Address - Country:US
Practice Address - Phone:850-431-4556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31953207R00000X
FLME16184207R00000X, 208M00000X
OH35-067214207R00000X
IN01051276A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2063109Medicaid
KY000000716795OtherBCBS
IN200109320Medicaid
110187934Medicare PIN
IN172580LMedicare PIN
INM400023741Medicare PIN
IN200109320Medicaid
OH2063109Medicaid
IN178440Medicare PIN