Provider Demographics
NPI:1033197264
Name:MUMFORD, MARK S (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:MUMFORD
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 1:501 20TH ST
Mailing Address - Street 2:SUITE 606
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-1809
Mailing Address - Country:US
Mailing Address - Phone:865-546-8040
Mailing Address - Fax:
Practice Address - Street 1:501 20TH ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-1863
Practice Address - Country:US
Practice Address - Phone:865-546-8040
Practice Address - Fax:865-541-2787
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13413207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN050011293OtherMCRR
TN3188681Medicaid
TN100010583OtherPHP TENNCARE
TN50019OtherBLUECROSS
TN50019OtherBLUECARE
TN050011293OtherMCRR
TN3188681Medicare PIN