=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083699128
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOURDES LLOREN MONTEZON MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2005
-----------------------------------------------------
Last Update Date | 02/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 492 ROUTE 57 W FX ANIDOME CTR
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07882-4338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-689-1000
-----------------------------------------------------
Fax | 908-689-4529
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 78 ANTHONY RD
-----------------------------------------------------
City | GLEN GARDNER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08826-3052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-832-6512
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MA50837
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------