Healthcare Provider Details

I. General information

NPI: 1265402663
Provider Name (Legal Business Name): JAY RANDALL MONTGOMERY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NATIONAL NAVAL MEDICAL CENTER 8901 WISCONSIN AVE
BETHESDA MD
20889-0001
US

IV. Provider business mailing address

NATIONAL NAVAL MEDICAL CTR 8901 WISCONSIN AVE.
BETHESDA MD
20889-0001
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-4510
  • Fax: 301-319-8299
Mailing address:
  • Phone: 301-295-4510
  • Fax: 301-319-8299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number0101241913
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: