Healthcare Provider Details

I. General information

NPI: 1629175377
Provider Name (Legal Business Name): SUMIT MAMUN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7330 SAN PEDRO AVE STE. 405
SAN ANTONIO TX
78216-6235
US

IV. Provider business mailing address

7330 SAN PEDRO AVE STE. 405
SAN ANTONIO TX
78216-6235
US

V. Phone/Fax

Practice location:
  • Phone: 210-344-2673
  • Fax: 210-344-2649
Mailing address:
  • Phone: 210-344-2673
  • Fax: 210-344-2649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberL0394
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL3094
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: