Provider Demographics
NPI:1154647568
Name:MUKHERJEE, SUMIT (MD)
Entity Type:Individual
Prefix:DR
First Name:SUMIT
Middle Name:
Last Name:MUKHERJEE
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:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:1 EDMUNDSON PL
Practice Address - Street 2:STE. 306
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4658
Practice Address - Country:US
Practice Address - Phone:712-396-7787
Practice Address - Fax:712-396-4115
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-41368207RP1001X
390200000X
MO2012014712207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026209700Medicaid
IA1154647568Medicaid
IA058970062Medicare PIN