Provider Demographics
NPI:1720089063
Name:TUMOLO, JOHN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:TUMOLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 SOUTH ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-4051
Mailing Address - Country:US
Mailing Address - Phone:508-765-0636
Mailing Address - Fax:508-764-4219
Practice Address - Street 1:100 SOUTH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-4051
Practice Address - Country:US
Practice Address - Phone:508-765-0636
Practice Address - Fax:508-764-4219
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA50918207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6176801Medicaid
MAA56895Medicare UPIN
MAJ03018Medicare ID - Type Unspecified