Provider Demographics
NPI:1093732612
Name:TJELLE, ERIC M (OD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:M
Last Name:TJELLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 HWY 59 SE
Mailing Address - Street 2:SUITE 1 BOX 505
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701
Mailing Address - Country:US
Mailing Address - Phone:218-681-3300
Mailing Address - Fax:218-681-6733
Practice Address - Street 1:1720 HWY 59 SE
Practice Address - Street 2:SUITE 1 BOX 505
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701
Practice Address - Country:US
Practice Address - Phone:218-681-3300
Practice Address - Fax:218-681-6733
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2833152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
644201041982OtherPREF
MN289M4TJOtherBC
2282569OtherMEDICA
MN928102900Medicaid
2282569OtherMEDICA
410002041Medicare ID - Type Unspecified