Provider Demographics
NPI:1467488551
Name:MONTGOMERY, SAMUEL JACOB JR (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JACOB
Last Name:MONTGOMERY
Suffix:JR
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:PO BOX 896189
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6189
Mailing Address - Country:US
Mailing Address - Phone:864-654-6706
Mailing Address - Fax:864-833-0520
Practice Address - Street 1:22995 US HIGHWAY 76
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-7529
Practice Address - Country:US
Practice Address - Phone:864-654-6706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC20855207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC180045119OtherRAILROAD MEDICARE
SCT49187Medicaid
SC180045119OtherRAILROAD MEDICARE
G89478Medicare UPIN