Provider Demographics
NPI:1407833080
Name:TIESZEN, MARK B (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:TIESZEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 W MAIN ST STE 34
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-2600
Mailing Address - Country:US
Mailing Address - Phone:719-859-1184
Mailing Address - Fax:
Practice Address - Street 1:134 W MAIN ST STE 34
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-2600
Practice Address - Country:US
Practice Address - Phone:719-859-1184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCHR.0008079111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA82570OtherGEISINGER HEALTH PLAN
PA1391293OtherHIGHMARK BCBS
PA82570OtherGEISINGER HEALTH PLAN
PA1391293OtherHIGHMARK BCBS