Provider Demographics
NPI:1770227795
Name:YOUNG, MONTGOMERY
Entity type:Individual
Prefix:
First Name:MONTGOMERY
Middle Name:
Last Name:YOUNG
Suffix:
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 1:5901 W BEHREND DR APT 2129
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6954
Mailing Address - Country:US
Mailing Address - Phone:714-488-1527
Mailing Address - Fax:
Practice Address - Street 1:7400 E OSBORN RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-6432
Practice Address - Country:US
Practice Address - Phone:480-882-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty