Provider Demographics
NPI:1508838384
Name:TIETJEN, DAVID P (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:P
Last Name:TIETJEN
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 1:2780 BOB WALLACE AVENUE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35805-4104
Mailing Address - Country:US
Mailing Address - Phone:256-534-4568
Mailing Address - Fax:
Practice Address - Street 1:2780 BOB WALLACE AVENUE
Practice Address - Street 2:SUITE E
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35805-4104
Practice Address - Country:US
Practice Address - Phone:256-533-4626
Practice Address - Fax:256-533-4710
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00019822207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E27678Medicare UPIN
AL000033711Medicare ID - Type Unspecified