Provider Demographics
NPI:1922060177
Name:SIELAFF, TIMOTHY D (MD PHD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
Last Name:SIELAFF
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E 28TH STREET
Mailing Address - Street 2:MAIL ROUTE 39602
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3799
Mailing Address - Country:US
Mailing Address - Phone:612-863-4633
Mailing Address - Fax:612-863-4689
Practice Address - Street 1:800 E 28TH STREET
Practice Address - Street 2:MAIL ROUTE 39602
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3799
Practice Address - Country:US
Practice Address - Phone:612-863-4633
Practice Address - Fax:612-863-4689
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35316208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G85313Medicare UPIN