Provider Demographics
NPI:1427175132
Name:TIONGKO, RUDOLPH N (MD)
Entity type:Individual
Prefix:
First Name:RUDOLPH
Middle Name:N
Last Name:TIONGKO
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 1:895 UNION ST
Mailing Address - Street 2:SUITE 12
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3053
Mailing Address - Country:US
Mailing Address - Phone:207-973-7979
Mailing Address - Fax:207-973-7684
Practice Address - Street 1:895 UNION ST
Practice Address - Street 2:SUITE 12
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3053
Practice Address - Country:US
Practice Address - Phone:207-973-7979
Practice Address - Fax:207-973-7684
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEEC061039390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program