Healthcare Provider Details

I. General information

NPI: 1578537460
Provider Name (Legal Business Name): JEFFREY MATTHEW TIONGSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JEFFREY MATTHEW TIONGSON MD

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY N
FARGO ND
58102-3641
US

IV. Provider business mailing address

801 BROADWAY N
FARGO ND
58102-3641
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-5121
  • Fax:
Mailing address:
  • Phone: 701-234-5121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number11220
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberD0053309
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: