Healthcare Provider Details

I. General information

NPI: 1215135553
Provider Name (Legal Business Name): JASON D GUMMA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6245 INKSTER RD
GARDEN CITY MI
48135-4001
US

IV. Provider business mailing address

8266 LAKE PINE DR
COMMERCE TOWNSHIP MI
48382-4527
US

V. Phone/Fax

Practice location:
  • Phone: 734-421-3300
  • Fax:
Mailing address:
  • Phone: 248-939-7117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101017228
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: