Basic Information
Provider Information | |||||||||
NPI: | 1851324834 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MULUMBA | ||||||||
FirstName: | MATIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MULUMBA | ||||||||
OtherFirstName: | MATIA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 2990 NORTON RD | ||||||||
Address2: |   | ||||||||
City: | GROVE CITY | ||||||||
State: | OH | ||||||||
PostalCode: | 431238964 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6148788283 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5263 NIKE STATION WAY | ||||||||
Address2: |   | ||||||||
City: | HILLIARD | ||||||||
State: | OH | ||||||||
PostalCode: | 430267449 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6148762100 | ||||||||
FaxNumber: | 6148762120 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2006 | ||||||||
LastUpdateDate: | 01/30/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35.085097 | OH | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2580443 | 05 | OH |   | MEDICAID |