Provider Demographics
NPI:1740276815
Name:TIETJEN, GRETCHEN E (MD)
Entity type:Individual
Prefix:DR
First Name:GRETCHEN
Middle Name:E
Last Name:TIETJEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3355 GLENDALE AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-2426
Mailing Address - Country:US
Mailing Address - Phone:419-291-3900
Mailing Address - Fax:419-479-6055
Practice Address - Street 1:2130 W CENTRAL AVE STE 201
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3819
Practice Address - Country:US
Practice Address - Phone:419-291-3900
Practice Address - Fax:419-479-6055
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350700232084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0226848Medicaid
OH0226848Medicaid
E87914Medicare UPIN