Provider Demographics
NPI:1134236979
Name:MUMFORD, CONSTANCE
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:MUMFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5943 STADIUM DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 S US 131
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093
Practice Address - Country:US
Practice Address - Phone:269-286-7070
Practice Address - Fax:269-286-7071
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301406834207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E38041Medicare UPIN