Provider Demographics
NPI:1063464683
Name:TIESZEN, MYLES ELDON (MD)
Entity Type:Individual
Prefix:
First Name:MYLES
Middle Name:ELDON
Last Name:TIESZEN
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 1:1601 SIOUX VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LUVERNE
Mailing Address - State:MN
Mailing Address - Zip Code:56156-4500
Mailing Address - Country:US
Mailing Address - Phone:507-283-4476
Mailing Address - Fax:507-283-9086
Practice Address - Street 1:1601 SIOUX VALLEY DR
Practice Address - Street 2:
Practice Address - City:LUVERNE
Practice Address - State:MN
Practice Address - Zip Code:56156
Practice Address - Country:US
Practice Address - Phone:507-283-4476
Practice Address - Fax:507-283-9086
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3813208600000X
IA38654208600000X
MN64861208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE46045455601Medicaid
SD7300264Medicaid
SD7300264Medicaid