Provider Demographics
NPI:1790733582
Name:TETZLAFF, THOMAS R (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:TETZLAFF
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 1450
Mailing Address - Street 2:NW0090
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55485-0090
Mailing Address - Country:US
Mailing Address - Phone:800-279-1395
Mailing Address - Fax:517-694-6441
Practice Address - Street 1:800 EAST 21ST STREET
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1016
Practice Address - Country:US
Practice Address - Phone:605-322-8000
Practice Address - Fax:702-853-8505
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV33742080P0203X
SD4674208000000X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016073Medicaid
MN1790733582Medicaid
SD6701390Medicaid
SD6701390Medicaid
SD6701390Medicaid