Healthcare Provider Details

I. General information

NPI: 1306848270
Provider Name (Legal Business Name): THOMAS W MONTAG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 WIMBLEDON SQ SUITE F
CHESAPEAKE VA
23320-4945
US

IV. Provider business mailing address

109 WIMBLEDON SQ SUITE F
CHESAPEAKE VA
23320-4945
US

V. Phone/Fax

Practice location:
  • Phone: 757-436-9898
  • Fax: 757-436-5455
Mailing address:
  • Phone: 757-436-9898
  • Fax: 757-436-5455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number0101059160
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: