Provider Demographics
NPI:1619972346
Name:BRIONES, TRISTAN STAELENA (MD)
Entity Type:Individual
Prefix:DR
First Name:TRISTAN
Middle Name:STAELENA
Last Name:BRIONES
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 1:1000 BRECKENRIDGE ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-0839
Mailing Address - Country:US
Mailing Address - Phone:270-926-7228
Mailing Address - Fax:270-926-6559
Practice Address - Street 1:1000 BRECKENRIDGE ST
Practice Address - Street 2:SUITE 203
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-0839
Practice Address - Country:US
Practice Address - Phone:270-926-7228
Practice Address - Fax:270-926-6559
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY173182085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000040652OtherANTHEM PROV.NUMBER
KY260109OtherBLACK LUNG
KY50003514OtherPASSPORT HEALTH PLAN
KY65907636Medicaid
KYRO 1278131OtherUMWA HEALTH & RETIREMENT
IN311034844001OtherBLUE SHIELD OF INDIANA
KY64173180Medicaid
KY000000040652OtherANTHEM PROV.NUMBER
KY0071103Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NUMBE
KY65907636Medicaid