Provider Demographics
NPI:1912927401
Name:TIEGS, VERNA G (MD)
Entity Type:Individual
Prefix:
First Name:VERNA
Middle Name:G
Last Name:TIEGS
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:PO BOX 240086
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-9186
Mailing Address - Country:US
Mailing Address - Phone:310-445-2800
Mailing Address - Fax:
Practice Address - Street 1:1516 COTNER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3303
Practice Address - Country:US
Practice Address - Phone:310-445-2951
Practice Address - Fax:310-479-1459
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG215312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G215310OtherBLUE SHIELD
CA00G215310Medicaid
CATG256BMedicare PIN
CATG042AMedicare PIN
CATP009Medicare PIN
CATP016AMedicare PIN
CATP016Medicare PIN
CAWG21531HMedicare PIN
CAWG21531IMedicare PIN
CAWG21531KMedicare PIN
CAWG21531JMedicare PIN
CATG256AMedicare PIN
CAWG21531FMedicare PIN
CA00G215310OtherBLUE SHIELD
CAWG21531GMedicare PIN
CATG053Medicare PIN
CATG042Medicare PIN