Provider Demographics
NPI:1609806736
Name:MONTALVO, MIGUEL A (MD)
Entity type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:A
Last Name:MONTALVO
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 1:1116 CREEK CABIN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-5835
Mailing Address - Country:US
Mailing Address - Phone:210-652-9500
Mailing Address - Fax:210-652-6615
Practice Address - Street 1:2200 BERGQUIST DR
Practice Address - Street 2:SUITE 1
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-9907
Practice Address - Country:US
Practice Address - Phone:210-292-6002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR006226171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider