Provider Demographics
NPI:1538151139
Name:MONTGOMERY, DAVID A (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
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 1:95 KINGSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9604
Mailing Address - Country:US
Mailing Address - Phone:270-465-3812
Mailing Address - Fax:270-465-8352
Practice Address - Street 1:95 KINGSWOOD DR
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-9604
Practice Address - Country:US
Practice Address - Phone:270-465-3812
Practice Address - Fax:270-465-8352
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29718207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0989813OtherMEDICARE HOSPITAL
KY29718OtherSTATE LICENSE
KY64297187Medicaid
KY64297187Medicaid
1383803Medicare ID - Type Unspecified
KY1383803Medicare PIN