Provider Demographics
NPI:1730157199
Name:TOMBERG, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:TOMBERG
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 1:1344 WINTERGREEN LN NE
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-5118
Mailing Address - Country:US
Mailing Address - Phone:206-842-5632
Mailing Address - Fax:206-842-5992
Practice Address - Street 1:1344 WINTERGREEN LN NE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110
Practice Address - Country:US
Practice Address - Phone:206-842-5632
Practice Address - Fax:206-842-5992
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037854207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00922338OtherRAIL ROAD MEDICARE
WA262519OtherLABOR & INDUSTRIES
WA8260010Medicaid
WAP01051934OtherRAILROAD MEDICARE
WA0294992OtherL AND I
WAG8918720Medicare PIN
WA8800887Medicare ID - Type Unspecified
WA0294992OtherL AND I
WAP00922338OtherRAIL ROAD MEDICARE
G8892013Medicare PIN
G8892011Medicare PIN
WAH22553Medicare UPIN
WA8260010Medicaid