Healthcare Provider Details

I. General information

NPI: 1487974085
Provider Name (Legal Business Name): NICOLE IRENE MONTGOMERY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2010
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 FANNIN ST
HOUSTON TX
77030-2608
US

IV. Provider business mailing address

1709 DRYDEN RD # 5.70
HOUSTON TX
77030-2400
US

V. Phone/Fax

Practice location:
  • Phone: 832-824-1000
  • Fax:
Mailing address:
  • Phone: 713-798-0190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License NumberR1992
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberBP10037400
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: