Healthcare Provider Details

I. General information

NPI: 1174667109
Provider Name (Legal Business Name): MOHAN KRISHNA TUMMALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 10/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 S FREMONT AVE SUITE 100
SPRINGFIELD MO
65804-2206
US

IV. Provider business mailing address

PO BOX 505164
SAINT LOUIS MO
63150-5164
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-8099
  • Fax: 417-820-8093
Mailing address:
  • Phone: 417-829-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number2011016083
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: