Provider Demographics
NPI:1922248566
Name:TIEDTKE, BLAKE (DPT)
Entity Type:Individual
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First Name:BLAKE
Middle Name:
Last Name:TIEDTKE
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Gender:M
Credentials:DPT
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Other - Credentials:
Mailing Address - Street 1:3290 RIDGEWAY DR
Mailing Address - Street 2:STE 3
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241
Mailing Address - Country:US
Mailing Address - Phone:319-665-2630
Mailing Address - Fax:319-665-2631
Practice Address - Street 1:645 32ND AVE SW
Practice Address - Street 2:STE A
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-3907
Practice Address - Country:US
Practice Address - Phone:319-363-2901
Practice Address - Fax:319-363-2903
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2020-03-04
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Provider Licenses
StateLicense IDTaxonomies
IA004341208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation