Provider Demographics
NPI:1003847971
Name:TOMBOULIAN, SHERRYL J (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:SHERRYL
Middle Name:J
Last Name:TOMBOULIAN
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:SISSETON
Mailing Address - State:SD
Mailing Address - Zip Code:57262-2312
Mailing Address - Country:US
Mailing Address - Phone:605-698-7681
Mailing Address - Fax:605-698-3493
Practice Address - Street 1:205 ORCHARD DR
Practice Address - Street 2:
Practice Address - City:SISSETON
Practice Address - State:SD
Practice Address - Zip Code:57262-2312
Practice Address - Country:US
Practice Address - Phone:605-698-7681
Practice Address - Fax:605-698-3493
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73423173000000X
CO49138207Q00000X
SD9632207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO47480777Medicaid
SDS110321Medicare PIN
CAG97195Medicare UPIN
COCOA105899Medicare PIN
CO47480777Medicaid