Healthcare Provider Details

I. General information

NPI: 1255455358
Provider Name (Legal Business Name): CLINTON MONTGOMERY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9650 ZELZAH AVE
NORTHRIDGE CA
91325-2003
US

IV. Provider business mailing address

9650 ZELZAH AVE
NORTHRIDGE CA
91325-2003
US

V. Phone/Fax

Practice location:
  • Phone: 818-993-9311
  • Fax:
Mailing address:
  • Phone: 661-265-8627
  • Fax: 661-265-7936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG9620
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: