Provider Demographics
NPI:1679559942
Name:MONTGOMERY, SAMUEL JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JAMES
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650865
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0865
Mailing Address - Country:US
Mailing Address - Phone:972-715-5007
Mailing Address - Fax:972-715-5682
Practice Address - Street 1:6606 LBJ FWY STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6524
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1067207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128571002Medicaid
TX128571006Medicaid
TX8888UGOtherBCBS TX
TX128571008Medicaid
TX322183002Medicaid
TX050065948OtherRAILROAD MEDICARE
TX128571007Medicaid
TX83763KOtherBCBS
TX8888UGOtherBCBS TX
TX128571002Medicaid
TX299191YK6UMedicare PIN
TX88978KMedicare PIN
D67425Medicare UPIN
TX128571006Medicaid