Provider Demographics
NPI:1518958990
Name:TIETZ, JUDITH (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:TIETZ
Suffix:
Gender:F
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 216
Mailing Address - Street 2:
Mailing Address - City:TOWNSHEND
Mailing Address - State:VT
Mailing Address - Zip Code:05353-0216
Mailing Address - Country:US
Mailing Address - Phone:802-365-7381
Mailing Address - Fax:
Practice Address - Street 1:185 GRAFTON RD.
Practice Address - Street 2:
Practice Address - City:TOWNSHEND
Practice Address - State:VT
Practice Address - Zip Code:05353
Practice Address - Country:US
Practice Address - Phone:802-365-7381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT04200091322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN0540Medicaid
F47258Medicare UPIN
473981Medicare Oscar/Certification
VTOVN0540Medicaid
VN0834Medicare Oscar/Certification