Provider Demographics
NPI:1760426324
Name:SUMULONG-TOMACRUZ, MARIVIC (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIVIC
Middle Name:
Last Name:SUMULONG-TOMACRUZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARIVIC
Other - Middle Name:
Other - Last Name:SUMULONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3605 W. 154TH STREET
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66224
Mailing Address - Country:US
Mailing Address - Phone:913-239-0314
Mailing Address - Fax:
Practice Address - Street 1:4101 SOUTH 4TH TRAFFICWAY
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048
Practice Address - Country:US
Practice Address - Phone:913-682-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-26592207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine