Provider Demographics
NPI:1639464050
Name:TIEVA, DANIEL MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:MARTIN
Last Name:TIEVA
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 4105
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4105
Mailing Address - Country:US
Mailing Address - Phone:866-907-1068
Mailing Address - Fax:425-917-9141
Practice Address - Street 1:3260 PROVIDENCE DR STE C436
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4661
Practice Address - Country:US
Practice Address - Phone:907-212-2273
Practice Address - Fax:907-212-6065
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-14
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK8150207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1615645Medicaid