Healthcare Provider Details

I. General information

NPI: 1568845667
Provider Name (Legal Business Name): NATHAN BUMBARGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WILFORD HALL LOOP BLDG 4554
JBSA LACKLAND TX
78236-5638
US

IV. Provider business mailing address

1100 WILFORD HALL LOOP BLDG 4554
JBSA LACKLAND TX
78236-5638
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-7934
  • Fax: 210-292-7934
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberD0095945
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0116027992
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: