Basic Information
| Provider Information | |||||||||
| NPI: | 1619912292 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | TVETENSTRAND | ||||||||
| FirstName: | CHRISTIAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 HARRISON ST | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077638205 | ||||||||
| FaxNumber: | 6077638208 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 HARRISON ST | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077638205 | ||||||||
| FaxNumber: | 6077638208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 178438 | NY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01135079 | 05 | NY | MEDICAID |