Provider Demographics
NPI:1831168236
Name:TETZLAFF, NAOMI P (MD)
Entity type:Individual
Prefix:
First Name:NAOMI
Middle Name:P
Last Name:TETZLAFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:NAOMI
Other - Middle Name:NICOLE
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:
Practice Address - Street 1:8611 W POINT DOUGLAS RD S
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-4005
Practice Address - Country:US
Practice Address - Phone:651-458-1884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39879207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN937317900Medicaid
MN937317900Medicaid
MN080020956Medicare PIN