Provider Demographics
NPI:1508086844
Name:TORNGREN, TRAVIS ROY (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:ROY
Last Name:TORNGREN
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 1:360 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2015
Mailing Address - Country:US
Mailing Address - Phone:208-356-9550
Mailing Address - Fax:415-928-1035
Practice Address - Street 1:360 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2015
Practice Address - Country:US
Practice Address - Phone:208-356-9550
Practice Address - Fax:208-356-8023
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11045207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1184799298Medicaid
ID1184799298Medicaid