Provider Demographics
NPI:1033167093
Name:RUMMEL, ROBERT MARK (MD, PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MARK
Last Name:RUMMEL
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 WILLOW CREEK RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1607
Mailing Address - Country:US
Mailing Address - Phone:928-445-1341
Mailing Address - Fax:928-778-3993
Practice Address - Street 1:1022 WILLOW CREEK RD
Practice Address - Street 2:SUITE 200
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1607
Practice Address - Country:US
Practice Address - Phone:928-445-1341
Practice Address - Fax:928-778-3993
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14391207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ250192Medicaid
AZ250192Medicaid
E41203Medicare UPIN