Healthcare Provider Details

I. General information

NPI: 1013628585
Provider Name (Legal Business Name): DEREK ANDREW MUMFORD IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 12/06/2022
Certification Date: 12/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RAF LAKENHEATH MAIN HOSPITAL BUILDING 932
APO AE
09461
US

IV. Provider business mailing address

PSC 37 BOX 3396
APO AE
09459-0034
US

V. Phone/Fax

Practice location:
  • Phone: 314-226-8010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: