Healthcare Provider Details

I. General information

NPI: 1851697023
Provider Name (Legal Business Name): MARK H MONTGOMERY MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2011
Last Update Date: 03/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9240 BONITA BEACH RD SE SUITE 1106
BONITA SPRINGS FL
34135-4249
US

IV. Provider business mailing address

9240 BONITA BEACH RD SE SUITE 1106
BONITA SPRINGS FL
34135-4249
US

V. Phone/Fax

Practice location:
  • Phone: 239-495-6200
  • Fax: 239-495-6247
Mailing address:
  • Phone: 239-495-6200
  • Fax: 239-495-6247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberME84347
License Number StateFL

VIII. Authorized Official

Name: DR. MARK H MONTGOMERY
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 239-495-6200