Basic Information
| Provider Information | |||||||||
| NPI: | 1487974085 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | IRENE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1709 DRYDEN RD # 5.70 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137980190 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1709 DRYDEN RD # 5.70 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137980190 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2010 | ||||||||
| LastUpdateDate: | 06/04/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | BP10037400 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 550301 | 01 | TX | PHYSICIAN IN TRAINING PERMIT | OTHER |