Provider Demographics
NPI:1306829015
Name:TRISTRAM, DEBRA A (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:A
Last Name:TRISTRAM
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:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:252-744-3253
Mailing Address - Fax:252-744-3194
Practice Address - Street 1:2150 HERBERT CT
Practice Address - Street 2:ECU PHYSICIANS PEDIATRIC SPECIALTY CARE CLINIC
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3736
Practice Address - Country:US
Practice Address - Phone:252-744-5437
Practice Address - Fax:252-744-1514
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98017882080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC11649OtherBCBS NC
NC8911649Medicaid
NC370015918OtherRAILROAD MEDICARE
NC2262105BMedicare PIN
NCG24975Medicare UPIN