Provider Demographics
NPI:1881663599
Name:MONTAGUE, PAUL (OD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:MONTAGUE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:CONYNGHAM
Mailing Address - State:PA
Mailing Address - Zip Code:18219-0310
Mailing Address - Country:US
Mailing Address - Phone:570-687-7943
Mailing Address - Fax:717-685-3250
Practice Address - Street 1:1129 QUENTIN RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-6915
Practice Address - Country:US
Practice Address - Phone:717-272-7059
Practice Address - Fax:717-272-2155
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002643152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004246543Medicaid
CT004246543Medicaid
CT410001130Medicare PIN