Provider Demographics
NPI:1871569095
Name:TUMMA, KAVITA (MD)
Entity type:Individual
Prefix:
First Name:KAVITA
Middle Name:
Last Name:TUMMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 PINE GROVE AVE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3500
Mailing Address - Country:US
Mailing Address - Phone:810-982-8742
Mailing Address - Fax:810-984-8291
Practice Address - Street 1:1231 PINE GROVE AVE
Practice Address - Street 2:SUITE 2A
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3500
Practice Address - Country:US
Practice Address - Phone:810-982-8742
Practice Address - Fax:810-984-8291
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060393207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1871569095Medicaid
G79823Medicare UPIN