Provider Demographics
NPI:1831720903
Name:TIETZEN, MARA AINSLEY (MD)
Entity type:Individual
Prefix:DR
First Name:MARA
Middle Name:AINSLEY
Last Name:TIETZEN
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 1:300 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-6000
Mailing Address - Fax:617-730-0683
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:857-218-4924
Practice Address - Fax:617-730-0683
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ41268208000000X
MA2836572080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty