Provider Demographics
NPI:1043322431
Name:ORELLANO, TRISTAN JORGE (MD)
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:JORGE
Last Name:ORELLANO
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 1:7350 VAN DUSEN RD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5264
Mailing Address - Country:US
Mailing Address - Phone:301-725-5557
Mailing Address - Fax:301-490-7637
Practice Address - Street 1:7350 VAN DUSEN RD
Practice Address - Street 2:SUITE 340
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5264
Practice Address - Country:US
Practice Address - Phone:301-725-5557
Practice Address - Fax:301-490-7637
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0017638208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD003971300Medicaid
142232Medicare ID - Type Unspecified
MD003971300Medicaid