Provider Demographics
NPI:1730184623
Name:TIESZEN, JEREL E (MD)
Entity type:Individual
Prefix:
First Name:JEREL
Middle Name:E
Last Name:TIESZEN
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 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-312-7605
Mailing Address - Fax:605-312-7611
Practice Address - Street 1:1205 S GRANGE AVE
Practice Address - Street 2:STE 510
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-0410
Practice Address - Country:US
Practice Address - Phone:605-328-7500
Practice Address - Fax:605-328-7599
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1158207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6000953Medicaid
SDS1017Medicare PIN
D25646Medicare UPIN
SDP00458476Medicare PIN
SD110227628Medicare PIN
SD6000953Medicaid