Provider Demographics
NPI:1265495774
Name:SUMERS, MARK ROBERT (MD, DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERT
Last Name:SUMERS
Suffix:
Gender:M
Credentials:MD, DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 JARRETT WHITE RD
Mailing Address - Street 2:TRIPLER ARMY MEDICAL CENTER
Mailing Address - City:TAMC
Mailing Address - State:HI
Mailing Address - Zip Code:96859-5001
Mailing Address - Country:US
Mailing Address - Phone:808-433-3300
Mailing Address - Fax:
Practice Address - Street 1:1 JARRETT WHITE RD
Practice Address - Street 2:TRIPLER ARMY MEDICAL CENTER
Practice Address - City:TAMC
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:808-433-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080614207Q00000X
HI13281207Q00000X
AZ34641207Q00000X
CAE3300213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4740479-10Medicaid
MI0N84060Medicare ID - Type Unspecified
MI4740479-10Medicaid