Basic Information
| Provider Information | |||||||||
| NPI: | 1659545713 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONTEJO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1031 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328021031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078727786 | ||||||||
| FaxNumber: | 4078723630 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 N ORANGE AVE | ||||||||
| Address2: | SUITE 181 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328044603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073032030 | ||||||||
| FaxNumber: | 4073032040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2008 | ||||||||
| LastUpdateDate: | 04/25/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 6894390-1205 | UT | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | ME109892 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | FE594 | 01 | FL | MEDICARE | OTHER | 3667100 | 05 | FL | MEDICAID |