Provider Demographics
NPI:1295718385
Name:MONTANA, ENRIQUE C (MD)
Entity type:Individual
Prefix:DR
First Name:ENRIQUE
Middle Name:C
Last Name:MONTANA
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 1:1221 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2829
Mailing Address - Country:US
Mailing Address - Phone:509-758-5511
Mailing Address - Fax:509-769-2022
Practice Address - Street 1:1119 HIGHLAND AVE STE 6
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2836
Practice Address - Country:US
Practice Address - Phone:509-254-2722
Practice Address - Fax:509-769-2022
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM- 10599208600000X
WAMD00047673208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD00047673OtherSTATE LICENCE
ID020000619OtherTRAVLERS RAILROAD
ID0433632Medicaid
ID4466435OtherAETNA
ID000000027381OtherANTHEM
WA8914858Medicare PIN
IDA79582Medicare UPIN
ID020000619OtherTRAVLERS RAILROAD