Provider Demographics
NPI:1508963950
Name:TINSATUL, UDOM (MD)
Entity Type:Individual
Prefix:
First Name:UDOM
Middle Name:
Last Name:TINSATUL
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:PO BOX 180
Mailing Address - Street 2:612 CENTER AVE N
Mailing Address - City:ASHLEY
Mailing Address - State:ND
Mailing Address - Zip Code:58413-0180
Mailing Address - Country:US
Mailing Address - Phone:701-288-3431
Mailing Address - Fax:701-288-3432
Practice Address - Street 1:612 CENTER AVE N
Practice Address - Street 2:
Practice Address - City:ASHLEY
Practice Address - State:ND
Practice Address - Zip Code:58413-7013
Practice Address - Country:US
Practice Address - Phone:701-288-3431
Practice Address - Fax:701-288-3432
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3926208600000X, 208D00000X
SD2268208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
450359987OtherCHAMPUS
ND12755Medicaid
ND1714OtherBCBS
ND450359987000OtherWORKERS COMP
SD7775690Medicaid
NDN1714Medicare PIN
450359987OtherCHAMPUS