Full Name | |
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Type | Facility |
Speciality | Ophthalmology |
Location | 279 E Elm, Lebanon, Missouri |
Accepts Medicare Assignments | Medicare enrolled and accepts medicare insurance. Providers at this facility may prescribe medicare part D drugs. |
Identifier | Type | State | Issuer |
---|---|---|---|
1316078868 | NPI | - | NPPES |
312368301 | Medicaid | MO |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
152W00000X | Optometrist | 2552 (Missouri) | Secondary |
207W00000X | Ophthalmology | TO2552 (Missouri) | Primary |
332H00000X | Eyewear Supplier | 2552 (Missouri) | Secondary |
Provider Name | Michael Montgomery |
---|---|
Provider Type | Practitioner - Optometry |
Provider Identifiers | NPI Number: 1124002969 PECOS PAC ID: 0244338309 Enrollment ID: I20070615000442 |
Mailing Address | Practice Location Address |
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Po Box 248, 279 East Elm, Lebanon, MO 65536-0248 Ph: (417) 532-2562 | 279 E Elm, Lebanon, MO 65536 Ph: (417) 532-2562 |