Provider Demographics
NPI:1881997815
Name:THOMAS, TRISTAN J (IDC)
Entity type:Individual
Prefix:MR
First Name:TRISTAN
Middle Name:J
Last Name:THOMAS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 DRIFTWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3155
Mailing Address - Country:US
Mailing Address - Phone:850-637-7482
Mailing Address - Fax:
Practice Address - Street 1:116 DRIFTWOOD CIR
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-3155
Practice Address - Country:US
Practice Address - Phone:850-637-7482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman