Healthcare Provider Details

I. General information

NPI: 1992929087
Provider Name (Legal Business Name): SAMUEL METZGER MUMMA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: PRAN M MUMMA D.O.M.

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9744 US HIGHWAY 301
DADE CITY FL
33525-1850
US

IV. Provider business mailing address

9744 US HIGHWAY 301
DADE CITY FL
33525-1850
US

V. Phone/Fax

Practice location:
  • Phone: 352-523-2876
  • Fax: 352-523-2830
Mailing address:
  • Phone: 352-523-2876
  • Fax: 352-523-2830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP 540
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: