Provider Demographics
NPI:1881700631
Name:TRISTINE, EDWARD MARTIN (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:MARTIN
Last Name:TRISTINE
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 1:17 CHURCH HILL RD
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-3116
Mailing Address - Country:US
Mailing Address - Phone:203-696-3550
Mailing Address - Fax:
Practice Address - Street 1:17 CHURCH HILL RD
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-3116
Practice Address - Country:US
Practice Address - Phone:203-696-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038590207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001385906Medicaid
CTH12686Medicare UPIN
CT110009711Medicare PIN