Provider Demographics
NPI:1265757116
Name:SUMABAT, TRISTAN JORDAN (MD)
Entity type:Individual
Prefix:DR
First Name:TRISTAN
Middle Name:JORDAN
Last Name:SUMABAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:167 CENTRE STREET
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L9V 3R8
Mailing Address - Country:CA
Mailing Address - Phone:519-925-0017
Mailing Address - Fax:519-925-6717
Practice Address - Street 1:167 CENTRE STREET
Practice Address - Street 2:
Practice Address - City:SHELBURNE
Practice Address - State:ONTARIO
Practice Address - Zip Code:L9V 3R8
Practice Address - Country:CA
Practice Address - Phone:519-925-0017
Practice Address - Fax:519-925-6717
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-05
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0116023022207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine