Provider Demographics
NPI:1821086380
Name:MUMMERT, CHRISTINA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:MARIE
Last Name:MUMMERT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:14413 ILLINOIS RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-9714
Mailing Address - Country:US
Mailing Address - Phone:260-616-0184
Mailing Address - Fax:855-271-9517
Practice Address - Street 1:14413 ILLINOIS RD
Practice Address - Street 2:SUITE C
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-9714
Practice Address - Country:US
Practice Address - Phone:260-616-0184
Practice Address - Fax:855-271-9517
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003334A152W00000X
MI4901004071152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN410029181OtherRR MEDICARE
IN669440Medicare PIN
IN410029181OtherRR MEDICARE