Provider Demographics
NPI:1609835115
Name:SUMIDA, MICHAEL P (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:SUMIDA
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 667
Mailing Address - Street 2:
Mailing Address - City:ETOWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37331-0667
Mailing Address - Country:US
Mailing Address - Phone:423-745-2344
Mailing Address - Fax:423-745-2314
Practice Address - Street 1:719 COOK DR
Practice Address - Street 2:STE 109
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-3495
Practice Address - Country:US
Practice Address - Phone:423-745-2344
Practice Address - Fax:423-745-2314
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD27304208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3096585Medicaid
TN3146634OtherBLUE CROSS BLUE SHIELD
TN3096585Medicaid
TNG18081Medicare UPIN