Provider Demographics
NPI:1861499584
Name:TIETZ, CHARLES ALBIN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALBIN
Last Name:TIETZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:307 1ST ST S
Mailing Address - Street 2:STE 108
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2696
Mailing Address - Country:US
Mailing Address - Phone:218-749-8326
Mailing Address - Fax:218-749-8608
Practice Address - Street 1:307 1ST ST S
Practice Address - Street 2:STE 108
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2696
Practice Address - Country:US
Practice Address - Phone:218-749-8326
Practice Address - Fax:218-749-8608
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN15922207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN77163TIOtherBCBS
MN07-02849OtherMEDICA
MN07-02849OtherMEDICA