Provider Demographics
NPI:1629415484
Name:TINKER, ELYSE C (DO)
Entity Type:Individual
Prefix:DR
First Name:ELYSE
Middle Name:C
Last Name:TINKER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 BENEDICT AVE.
Mailing Address - Street 2:BLDG C. STE 1
Mailing Address - City:NORWALK
Mailing Address - State:OH
Mailing Address - Zip Code:44857
Mailing Address - Country:US
Mailing Address - Phone:419-668-1101
Mailing Address - Fax:419-668-1191
Practice Address - Street 1:257 BENEDICT AVE STE 1
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:OH
Practice Address - Zip Code:44857-2715
Practice Address - Country:US
Practice Address - Phone:419-668-1101
Practice Address - Fax:419-668-1191
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.012625207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0215696Medicaid
IL036139189Medicaid
ILF400339944Medicare PIN