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General NPI Number Information
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NPI Number | 1588310734
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Entity Type | Individual
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Provider Name | MARLON JOSE MONTENEGRO CSFA
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Gender | Male
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Dates
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Enumeration Date | 02/25/2022
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Last Update Date | 02/25/2022
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Provider Practice Location Address
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Address Line | 2125 STATE ST STE 6
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City | NEW ALBANY
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State | IN
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Zip | 47150-4972
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Country | US
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Telephone | 812-948-7417
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Fax |
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Provider Business Mailing Address
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Address Line | 8338 WABASH AVE
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City | TERRE HAUTE
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State | IN
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Zip | 47803-3982
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Country | US
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Telephone | 138-630-2394
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 20-391
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 20-931
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License Number State | WI
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