Basic Information
| Provider Information | |||||||||
| NPI: | 1043306947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIRTAMAN-SIE | ||||||||
| FirstName: | CONNY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TIRTAMAN | ||||||||
| OtherFirstName: | CONNY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1576 | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923541576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098257084 | ||||||||
| FaxNumber: | 9095836726 | ||||||||
| Practice Location | |||||||||
| Address1: | 11201 BENTON ST | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923571000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098257084 | ||||||||
| FaxNumber: | 9095836726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00040886 | WA | X | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME0083971 | FL | X | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | C52357 | CA | X | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | C52357 | CA | X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.