Healthcare Provider Details

I. General information

NPI: 1811972185
Provider Name (Legal Business Name): MICHELLE CUMMINS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 06/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N VIRGINIA ST SUITE 112
PORT LAVACA TX
77979-2516
US

IV. Provider business mailing address

PO BOX 5511
VICTORIA TX
77903-5511
US

V. Phone/Fax

Practice location:
  • Phone: 361-551-2565
  • Fax: 361-551-2568
Mailing address:
  • Phone: 361-551-2565
  • Fax: 361-551-2568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberK9250
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: