Provider Demographics
NPI:1144313156
Name:MONTGOMERY, DONALD WAYNE (DPM)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:WAYNE
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:DONALD
Other - Middle Name:WAYNE
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:3520 FANNIN ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-3813
Mailing Address - Country:US
Mailing Address - Phone:409-832-5956
Mailing Address - Fax:409-832-2671
Practice Address - Street 1:3520 FANNIN ST
Practice Address - Street 2:SUITE #1
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-3813
Practice Address - Country:US
Practice Address - Phone:409-832-5956
Practice Address - Fax:409-832-2671
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0869213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092759201Medicaid
TX00BY60Medicare PIN
TXT14877Medicare UPIN