Provider Demographics
NPI:1265426993
Name:MUMMERT, TIMOTHY WAYNE (DO)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:MUMMERT
Suffix:
Gender:M
Credentials:DO
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 40
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-0040
Mailing Address - Country:US
Mailing Address - Phone:419-734-5587
Mailing Address - Fax:419-732-1553
Practice Address - Street 1:1250 FULTON ST
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-9296
Practice Address - Country:US
Practice Address - Phone:419-734-5587
Practice Address - Fax:419-732-1553
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH005235207R00000X
OH34-005235208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0815461Medicaid
OH0815461Medicaid