Provider Demographics
NPI:1780686352
Name:TUMMINELLO, SAM C (MD)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:C
Last Name:TUMMINELLO
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 1:19 SERGEANT PRENTISS DR
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4727
Mailing Address - Country:US
Mailing Address - Phone:601-442-8437
Mailing Address - Fax:601-442-8442
Practice Address - Street 1:19 SERGEANT PRENTISS DR
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4727
Practice Address - Country:US
Practice Address - Phone:601-442-8437
Practice Address - Fax:601-442-8442
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11638207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018547Medicaid
LA1379999Medicaid
LA1379999Medicaid