Provider Demographics
NPI:1043306947
Name:TIRTAMAN-SIE, CONNY (MD)
Entity Type:Individual
Prefix:DR
First Name:CONNY
Middle Name:
Last Name:TIRTAMAN-SIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CONNY
Other - Middle Name:
Other - Last Name:TIRTAMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1576
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-1576
Mailing Address - Country:US
Mailing Address - Phone:909-825-7084
Mailing Address - Fax:909-583-6726
Practice Address - Street 1:11201 BENTON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357-1000
Practice Address - Country:US
Practice Address - Phone:909-825-7084
Practice Address - Fax:909-583-6726
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00040886207R00000X
FLME0083971207R00000X
CAC52357207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease