Provider Demographics
NPI:1952706574
Name:THIESMEYER, MARK (RD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:THIESMEYER
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 ABBOTT AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-4103
Mailing Address - Country:US
Mailing Address - Phone:734-644-5486
Mailing Address - Fax:
Practice Address - Street 1:1507 ABBOTT AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-4103
Practice Address - Country:US
Practice Address - Phone:734-644-5486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI944489133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered