Provider Demographics
NPI:1205225117
Name:MONTGOMERY, TOM III
Entity type:Individual
Prefix:MR
First Name:TOM
Middle Name:
Last Name:MONTGOMERY
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1929 BETTY JANE LN
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-1581
Mailing Address - Country:US
Mailing Address - Phone:918-683-9407
Mailing Address - Fax:
Practice Address - Street 1:1929 BETTY JANE LN
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-1581
Practice Address - Country:US
Practice Address - Phone:918-683-9407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2286376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200106120AMedicaid
OK375174OtherMEDICARE PROVIDER ENROLLMENT