Healthcare Provider Details

I. General information

NPI: 1306830013
Provider Name (Legal Business Name): ANTHONY JOSEPH MONTEGUT SR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 03/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15221 SPRAGUE ST
OMAHA NE
68116-4261
US

IV. Provider business mailing address

15221 SPRAGUE ST
OMAHA NE
68116-4261
US

V. Phone/Fax

Practice location:
  • Phone: 402-614-3703
  • Fax:
Mailing address:
  • Phone: 402-614-3703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number36831
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101234489
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: