Provider Demographics
NPI:1023384831
Name:TIETJENS, JEREMY R (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:R
Last Name:TIETJENS
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 1:3023 N BALLAS RD STE 200D
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2328
Mailing Address - Country:US
Mailing Address - Phone:314-996-7272
Mailing Address - Fax:
Practice Address - Street 1:3023 N BALLAS RD STE 200D
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2328
Practice Address - Country:US
Practice Address - Phone:314-996-7272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020020220207R00000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine