Provider Demographics
NPI:1871645663
Name:TEGGATZ, TANYA BRUSTER (MD)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:BRUSTER
Last Name:TEGGATZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:
Other - Last Name:BRUSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5100 FOUNTAINS DR. N.E. STE 102
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52411
Mailing Address - Country:US
Mailing Address - Phone:319-393-4307
Mailing Address - Fax:319-294-6912
Practice Address - Street 1:5264 COUNCIL ST NE
Practice Address - Street 2:SUITE 100
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-2471
Practice Address - Country:US
Practice Address - Phone:319-221-8444
Practice Address - Fax:319-221-8589
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA32590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA4154062Medicaid
IAI19063Medicare PIN
IAG60671Medicare UPIN