Healthcare Provider Details

I. General information

NPI: 1659545713
Provider Name (Legal Business Name): MICHAEL EDWARD MONTEJO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 N ORANGE AVE SUITE 181
ORLANDO FL
32804-4603
US

IV. Provider business mailing address

PO BOX 1031
ORLANDO FL
32802-1031
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-2030
  • Fax: 407-303-2040
Mailing address:
  • Phone: 407-872-7786
  • Fax: 407-872-3630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number6894390-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberME109892
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: