Provider Demographics
NPI:1255443024
Name:CUMBERWORTH, WILLIAM A (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:CUMBERWORTH
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 1:657A WEST MAPLE STREET
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:87401
Mailing Address - Country:US
Mailing Address - Phone:505-325-5025
Mailing Address - Fax:505-325-0689
Practice Address - Street 1:657A WEST MAPLE STREET
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NY
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-325-5025
Practice Address - Fax:505-325-0689
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM70-29207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM004695OtherBSHIELD
NM0645Medicaid
D35588Medicare UPIN