Provider Demographics
NPI:1013994805
Name:TIEDEKEN, PATRICK T (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:T
Last Name:TIEDEKEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2170 NOLL DR STE 400
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-7609
Mailing Address - Country:US
Mailing Address - Phone:717-417-8950
Mailing Address - Fax:
Practice Address - Street 1:2170 NOLL DR STE 400
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-7609
Practice Address - Country:US
Practice Address - Phone:717-417-8950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-025186E207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA180021953OtherMEDICARE RAILROAD
PA01208917Medicaid
E04277Medicare UPIN
PA0000141977Medicare NSC
PATI141977Medicare PIN