1265757116 NPI number — DR. TRISTAN JORDAN SUMABAT M.D.

Table of content: DR. TRISTAN JORDAN SUMABAT M.D. (NPI 1265757116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265757116 NPI number — DR. TRISTAN JORDAN SUMABAT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUMABAT
Provider First Name:
TRISTAN
Provider Middle Name:
JORDAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265757116
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
167 CENTRE STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELBURNE
Provider Business Mailing Address State Name:
ONTARIO
Provider Business Mailing Address Postal Code:
L9V 3R8
Provider Business Mailing Address Country Code:
CA
Provider Business Mailing Address Telephone Number:
519-925-0017
Provider Business Mailing Address Fax Number:
519-925-6717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
167 CENTRE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBURNE
Provider Business Practice Location Address State Name:
ONTARIO
Provider Business Practice Location Address Postal Code:
L9V 3R8
Provider Business Practice Location Address Country Code:
CA
Provider Business Practice Location Address Telephone Number:
519-925-0017
Provider Business Practice Location Address Fax Number:
519-925-6717
Provider Enumeration Date:
04/05/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0116023022 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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