Provider Demographics
NPI:1457386773
Name:MONTGOMERY, THOMAS JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOSEPH
Last Name:MONTGOMERY
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 1:330 W MARTIAL AVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6711
Mailing Address - Country:US
Mailing Address - Phone:337-406-2661
Mailing Address - Fax:
Practice Address - Street 1:1301 CAMELLIA BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-7089
Practice Address - Country:US
Practice Address - Phone:337-235-2264
Practice Address - Fax:337-232-4426
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020154207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1449121Medicaid
0973450001Medicare NSC
LA5U319CN17Medicare ID - Type Unspecified
LAF55307Medicare UPIN