Provider Demographics
NPI:1477230670
Name:POLINTAN, EDGAR THEODORE TUMANGUIL (MD)
Entity Type:Individual
Prefix:DR
First Name:EDGAR THEODORE
Middle Name:TUMANGUIL
Last Name:POLINTAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 CLAYTON ROAD SSM HEALTH ST. MARY'S HOSPITAL-ST LOU
Mailing Address - Street 2:DEPARTMENT OF INTERNAL MEDICINE
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117
Mailing Address - Country:US
Mailing Address - Phone:314-768-8778
Mailing Address - Fax:
Practice Address - Street 1:6420 CLAYTON ROAD SSM HEALTH ST. MARY'S HOSPITAL-ST LOU
Practice Address - Street 2:DEPARTMENT OF INTERNAL MEDICINE
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117
Practice Address - Country:US
Practice Address - Phone:314-768-8778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023016707390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2023016707OtherMISSOURI PHYSICIAN LICENSENUMBER