Provider Demographics
NPI:1124912423
Name:MONTGOMERY, TYSON (OD)
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:
Last Name:MONTGOMERY
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 1:1457 NEIL AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-2602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:676 FUTENMA
Practice Address - Street 2:
Practice Address - City:FUTENMA
Practice Address - State:OKINAWA
Practice Address - Zip Code:90122
Practice Address - Country:JP
Practice Address - Phone:098-971-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-03
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.007367152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist