MEDICARE: DR. GREGORY G MONTAVON O.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	35556/T794	OH

General Provider Information

NPI Number	:	1154383883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY G MONTAVON O.D

Provider Business Mailing Address
First Line	:	414 W EMMITT AVE
Second Line	:
City	:	WAVERLY
State	:	OH
Zip	:	45690-1008
Country	:	US
Telephone Number	:	740-947-8191
Fax Number	:	740-947-5554

Provider Business Practice Location Address
First Line	:	414 W EMMITT AVE
Second Line	:
City	:	WAVERLY
State	:	OH
Zip	:	45690-1008
Country	:	US
Telephone Number	:	740-947-8191
Fax Number	:	740-947-5554

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	09/03/2014

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