Provider Demographics
NPI:1295907764
Name:MUMMERT, DIANA I (MD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:I
Last Name:MUMMERT
Suffix:
Gender:F
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 99335
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0335
Mailing Address - Country:US
Mailing Address - Phone:817-735-2400
Mailing Address - Fax:817-735-0615
Practice Address - Street 1:855 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2553
Practice Address - Country:US
Practice Address - Phone:817-735-2400
Practice Address - Fax:817-735-0615
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM88582084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196134401Medicaid
TX8X5114OtherBCBS
TXP00723129OtherRAILROAD MEDICARE
TX196134401Medicaid