Provider Demographics
NPI:1457332991
Name:MUMMERT, AMY I (OD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:I
Last Name:MUMMERT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-2629
Mailing Address - Country:US
Mailing Address - Phone:231-947-2121
Mailing Address - Fax:231-933-6313
Practice Address - Street 1:522 E 8TH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2629
Practice Address - Country:US
Practice Address - Phone:231-947-2121
Practice Address - Fax:231-933-6313
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003582152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU81573Medicare UPIN
MION76980Medicare ID - Type Unspecified
MI3882910001Medicare NSC