Provider Demographics
NPI:1285644195
Name:TINGSTAD, EDWIN M (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:M
Last Name:TINGSTAD
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 1:2500 W A ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-6000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 W A ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-6000
Practice Address - Country:US
Practice Address - Phone:208-883-2828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA37180207X00000X
IDM8045207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1110857Medicaid
ID805780700Medicaid
WA135969OtherWA DEPT OF LABOR
ID805780700Medicaid
4856030001Medicare NSC
WA1110857Medicaid
ID805780700Medicaid