1124019427 NPI number — DR. VERNON P MONTOYA M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124019427 NPI number — DR. VERNON P MONTOYA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONTOYA
Provider First Name:
VERNON
Provider Middle Name:
P
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124019427
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
289 SW STONEGATE TERR
Provider Second Line Business Practice Location Address:
SUITE #103
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32024-3457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-755-1655
Provider Business Practice Location Address Fax Number:
386-755-2330
Provider Enumeration Date:
11/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RX0202X , with the licence number:  ME61981 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RH0003X , with the licence number: ME61981 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 370445900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: K9539 . This is a "MEDICARE GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PTAN 14993U . This is a "LINKED TO GROUP PTAN IE881A EFFECTIVE 07/01/15" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 14993 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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