Healthcare Provider Details

I. General information

NPI: 1750735080
Provider Name (Legal Business Name): BRIAN MONTEVIRGEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2016
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 CLARKSON AVE BOX 59
BROOKLYN NY
11203-2012
US

IV. Provider business mailing address

450 CLARKSON AVE BOX 59
BROOKLYN NY
11203-2012
US

V. Phone/Fax

Practice location:
  • Phone: 718-270-2078
  • Fax:
Mailing address:
  • Phone: 718-270-2078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number300430
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: