Provider Demographics
NPI:1366475063
Name:GUEVARA, TRISTAN (DO)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:GUEVARA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43455 SCHOENHERR RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-1951
Mailing Address - Country:US
Mailing Address - Phone:586-726-4823
Mailing Address - Fax:586-726-8365
Practice Address - Street 1:43455 SCHOENHERR RD
Practice Address - Street 2:SUITE 2
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1951
Practice Address - Country:US
Practice Address - Phone:586-726-4823
Practice Address - Fax:586-726-8365
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013889207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION58330011Medicare PIN
MIH56119Medicare UPIN