Provider Demographics
NPI:1679522700
Name:TIETJEN, DOUGLAS N (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:N
Last Name:TIETJEN
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 1:451 NW MURRAY RD
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64081-1425
Mailing Address - Country:US
Mailing Address - Phone:816-524-1007
Mailing Address - Fax:816-524-1988
Practice Address - Street 1:451 NW MURRAY RD
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64081-1425
Practice Address - Country:US
Practice Address - Phone:816-524-1007
Practice Address - Fax:816-524-1988
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0428228174400000X
MO118291174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205101Medicaid
340016722OtherRR MEDICARE
MO25977052OtherBCBS
340016722OtherRR MEDICARE
MO205101Medicaid
KSJ719922Medicare PIN