Provider Demographics
NPI:1164463113
Name:MUMFORD, BRETT T (DO)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:T
Last Name:MUMFORD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-476-5777
Mailing Address - Fax:208-476-5385
Practice Address - Street 1:301 CEDAR ST
Practice Address - Street 2:
Practice Address - City:OROFINO
Practice Address - State:ID
Practice Address - Zip Code:83544-9029
Practice Address - Country:US
Practice Address - Phone:208-476-5777
Practice Address - Fax:208-476-5385
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO266207Q00000X
IDO-266207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR139263Medicare PIN
ID1302636Medicare ID - Type Unspecified