Provider Demographics
NPI:1982678835
Name:TIETZE, PAMELA HODGES (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:HODGES
Last Name:TIETZE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 NE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5420
Mailing Address - Country:US
Mailing Address - Phone:405-271-4311
Mailing Address - Fax:405-271-2797
Practice Address - Street 1:900 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5420
Practice Address - Country:US
Practice Address - Phone:405-271-4311
Practice Address - Fax:405-271-2797
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18715207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100148940BMedicaid
OK800522535OtherMEDICARE GROUP PIN
C72861Medicare UPIN
OK800522535OtherMEDICARE GROUP PIN