Healthcare Provider Details

I. General information

NPI: 1922412600
Provider Name (Legal Business Name): DAVID EDWARD TIESMA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 MICHIGAN ST NE STE 8100
GRAND RAPIDS MI
49503-2531
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-0800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301106108
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301106108
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: