MEDICARE: DR. VERNON P MONTOYA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RX0202X	Medical Oncology Physician	ME61981	FL
2	207RH0003X	Hematology & Oncology Physician	ME61981	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	K9539	OTHER	FL	MEDICARE GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	PTAN 14993U	OTHER	FL	LINKED TO GROUP PTAN IE881A EFFECTIVE 07/01/15
4	14993	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1124019427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VERNON P MONTOYA M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1642
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32056-1642
Country	:	US
Telephone Number	:	386-755-1655
Fax Number	:	386-755-2330

Provider Business Practice Location Address
First Line	:	289 SW STONEGATE TERR
Second Line	:	SUITE #103
City	:	LAKE CITY
State	:	FL
Zip	:	32024-3457
Country	:	US
Telephone Number	:	386-755-1655
Fax Number	:	386-755-2330

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	03/16/2023

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Directions to “ DR. VERNON P MONTOYA M.D.” Practice Location

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