Provider Demographics
NPI:1467486829
Name:TIETZ, FREDRIC (MD)
Entity Type:Individual
Prefix:
First Name:FREDRIC
Middle Name:
Last Name:TIETZ
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:PO BOX 6096
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-6096
Mailing Address - Country:US
Mailing Address - Phone:541-548-8131
Mailing Address - Fax:541-706-3765
Practice Address - Street 1:1253 NW CANAL BLVD
Practice Address - Street 2:ST. CHARLES MEDICAL CENTER REDMOND
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756
Practice Address - Country:US
Practice Address - Phone:541-548-8131
Practice Address - Fax:541-706-3765
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50497207P00000X
ORMD166601207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA51702Medicare UPIN
CABS267ZMedicare PIN