Provider Demographics
NPI:1205124732
Name:MONTGOMERY, BRANDI (OD)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 ELDRIDGE PKWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-2543
Mailing Address - Country:US
Mailing Address - Phone:281-759-3937
Mailing Address - Fax:
Practice Address - Street 1:1140 ELDRIDGE PKWY
Practice Address - Street 2:120
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-2543
Practice Address - Country:US
Practice Address - Phone:806-676-1713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7712TG152W00000X, 152WC0802X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB153100Medicare UPIN
TXTXB153100Medicare PIN