Provider Demographics
NPI:1144226234
Name:MONTGOMERY, GORDON JAMES (MD)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:JAMES
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 1:835 THIRD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-1352
Mailing Address - Country:US
Mailing Address - Phone:619-425-7755
Mailing Address - Fax:619-425-2138
Practice Address - Street 1:835 THIRD AVE STE A
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1352
Practice Address - Country:US
Practice Address - Phone:619-425-7755
Practice Address - Fax:619-425-2138
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2020-08-26
Deactivation Date:2006-04-05
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
CAG31591174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G5315910Medicaid
CA00G315911Medicaid
CAWG31591DOtherMEDICARE PIN # (R)
CAWG31591AMedicare PIN