Healthcare Provider Details

I. General information

NPI: 1164463113
Provider Name (Legal Business Name): BRETT T MUMFORD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 CEDAR ST
OROFINO ID
83544-9029
US

IV. Provider business mailing address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

V. Phone/Fax

Practice location:
  • Phone: 208-476-5777
  • Fax: 208-476-5385
Mailing address:
  • Phone: 208-476-5777
  • Fax: 208-476-5385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO266
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberO-266
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: