Healthcare Provider Details

I. General information

NPI: 1285792374
Provider Name (Legal Business Name): MICHAEL RAY GUMMOW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 09/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 INDEPENDENCE RD
CANON CITY CO
81212-9380
US

IV. Provider business mailing address

3225 INDEPENDENCE RD
CANON CITY CO
81212-9380
US

V. Phone/Fax

Practice location:
  • Phone: 719-275-2351
  • Fax:
Mailing address:
  • Phone: 719-275-2351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberR-7895
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number48133
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: