Provider Demographics
NPI:1912951476
Name:TIEDT, DOUGLAS L (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:L
Last Name:TIEDT
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 1897
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29721-1897
Mailing Address - Country:US
Mailing Address - Phone:803-286-6997
Mailing Address - Fax:803-283-3999
Practice Address - Street 1:1370 W MEETING ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-2222
Practice Address - Country:US
Practice Address - Phone:803-286-6997
Practice Address - Fax:803-283-3999
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13596207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC135963Medicaid
SC135963Medicaid