Healthcare Provider Details

I. General information

NPI: 1033503255
Provider Name (Legal Business Name): NATHANIEL MONTAG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 GRAND AVE
ENGLEWOOD NJ
07631-4967
US

IV. Provider business mailing address

355 W 16TH ST
INDIANAPOLIS IN
46202-2207
US

V. Phone/Fax

Practice location:
  • Phone: 201-567-2277
  • Fax:
Mailing address:
  • Phone: 317-963-7077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number296383-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number02005347A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number25MB10420400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: