Provider Demographics
NPI:1215969902
Name:LUMI, CRYSTAL FIALOVA (MD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:FIALOVA
Last Name:LUMI
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 1:15552 68TH PL N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3291
Mailing Address - Country:US
Mailing Address - Phone:931-237-2265
Mailing Address - Fax:612-594-8998
Practice Address - Street 1:15552 68TH PL N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-3291
Practice Address - Country:US
Practice Address - Phone:931-237-2265
Practice Address - Fax:612-594-8998
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39691208600000X
AL28928208600000X
WI37412208600000X
TN46661208600000X
VT0420012124208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1523162Medicaid
MN514517100Medicaid
AL510G700277Medicare PIN
TN1523162Medicaid
F69382Medicare UPIN
TN1523162Medicaid