Provider Demographics
NPI:1477689578
Name:KONZER, TIA RENE' (DO)
Entity Type:Individual
Prefix:DR
First Name:TIA
Middle Name:RENE'
Last Name:KONZER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 RANDOLPH RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1122
Mailing Address - Country:US
Mailing Address - Phone:704-384-1246
Mailing Address - Fax:704-384-6072
Practice Address - Street 1:1900 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1122
Practice Address - Country:US
Practice Address - Phone:704-384-1246
Practice Address - Fax:704-384-6072
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010160632084P0800X
NC2009-014422084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912201Medicaid