Provider Demographics
NPI:1134213796
Name:STONGER, TRISTAN VAUN (MD)
Entity type:Individual
Prefix:DR
First Name:TRISTAN
Middle Name:VAUN
Last Name:STONGER
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 1:1 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-2231
Mailing Address - Country:US
Mailing Address - Phone:765-432-5294
Mailing Address - Fax:765-472-7700
Practice Address - Street 1:1 S BROADWAY
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-2231
Practice Address - Country:US
Practice Address - Phone:765-432-5294
Practice Address - Fax:765-472-7700
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4581204E00000X, 208200000X, 2082S0099X, 2082S0105X
IN01031765A204E00000X, 208200000X, 2082S0099X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN209490Medicare ID - Type UnspecifiedMEDICARE NUMBER
INB29159Medicare UPIN