Provider Demographics
NPI:1982674305
Name:MUMFORD, MICHAEL THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:MUMFORD
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 1:3617 S TIMBER ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92707-4947
Mailing Address - Country:US
Mailing Address - Phone:714-540-1924
Mailing Address - Fax:714-540-1309
Practice Address - Street 1:2740 S BRISTOL ST
Practice Address - Street 2:SUITE 216
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-6209
Practice Address - Country:US
Practice Address - Phone:714-540-1924
Practice Address - Fax:714-540-6302
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36179207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA91754Medicare UPIN
CAG36179Medicare PIN