Basic Information
| Provider Information | |||||||||
| NPI: | 1316928757 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZUMWALT | ||||||||
| FirstName: | MIMI | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5865 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794305865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432898 | ||||||||
| FaxNumber: | 8067432787 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794300002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432475 | ||||||||
| FaxNumber: | 8067431394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2005 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | K8867 | TX | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | K8867 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100078050A | 05 | OK | MEDICAID | 64481 | 05 | NM | MEDICAID | 81155S | 01 | TX | BC/BS | OTHER | 105457903 | 05 | TX | MEDICAID | 66627 | 05 | NM | MEDICAID | BZ5764546 | 01 | TX | DEA | OTHER | 105457901 | 05 | TX | MEDICAID | A033 | 01 | NM | TRIWEST | OTHER | X0112999 | 01 | TX | DPS | OTHER | 64481 | 01 | NM | PRESBYTERIAN COMMERCIAL | OTHER | 84308Z | 01 | TX | HMO BLUE | OTHER | 127647100 | 01 | TX | FIRSTCARE COMMERCIAL | OTHER | 127647101 | 05 | TX | MEDICAID |