Provider Demographics
NPI:1255323317
Name:GUMBO, TAWANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:TAWANDA
Middle Name:
Last Name:GUMBO
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 1:5323 HARRY HINES BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-9113
Mailing Address - Country:US
Mailing Address - Phone:214-648-9914
Mailing Address - Fax:214-648-2741
Practice Address - Street 1:UT SOUTHWESTERN MEDICAL CTR
Practice Address - Street 2:5323 HARRY HINES BLVD
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-9113
Practice Address - Country:US
Practice Address - Phone:214-648-9914
Practice Address - Fax:214-648-2741
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002080207RI0200X
TX41626207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02353648Medicaid
NY02353648Medicaid
NYCC4934Medicare ID - Type Unspecified