Provider Demographics
NPI:1073704813
Name:CUMBERLAND, MELISHA
Entity Type:Individual
Prefix:
First Name:MELISHA
Middle Name:
Last Name:CUMBERLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1253
Mailing Address - Country:US
Mailing Address - Phone:203-709-6000
Mailing Address - Fax:
Practice Address - Street 1:56 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1253
Practice Address - Country:US
Practice Address - Phone:203-709-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT50051207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT635099OtherWELLCARE
CTP01117224OtherRAILROAD MEDICARE
CT1156121OtherUSA
CTP4387957OtherOXFORD
CTP01117224OtherRAILROAD MEDICARE