Provider Demographics
NPI:1730309899
Name:DAMMIN, TRISTRAM C (MD)
Entity Type:Individual
Prefix:
First Name:TRISTRAM
Middle Name:C
Last Name:DAMMIN
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 1:41 MALL RAOD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8000
Mailing Address - Fax:781-744-5659
Practice Address - Street 1:41 MALL RAOD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8000
Practice Address - Fax:781-744-5659
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA42019207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6199666Medicaid
MAB97391Medicare UPIN
MA6199666Medicaid