Basic Information
Provider Information | |||||||||
NPI: | 1275829954 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MONTOYA | ||||||||
FirstName: | RAYMOND | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | II | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 259 E ERIE ST STE 2230 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606113370 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3129266000 | ||||||||
FaxNumber: | 3129268267 | ||||||||
Practice Location | |||||||||
Address1: | 259 E ERIE ST STE 2230 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606113370 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3129266000 | ||||||||
FaxNumber: | 3129268267 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/21/2011 | ||||||||
LastUpdateDate: | 07/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 016005559 | IL | N |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 207XX0004X | 135000730 | IL | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 213E00000X | 016005559 | IL | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
ID Information
ID | Type | State | Issuer | Description | 364322013 | 05 | IL |   | MEDICAID |