Healthcare Provider Details

I. General information

NPI: 1467486829
Provider Name (Legal Business Name): FREDRIC TIETZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61250 SE COOMBS PL
BEND OR
97702-3704
US

IV. Provider business mailing address

PO BOX 6096
BEND OR
97708-6096
US

V. Phone/Fax

Practice location:
  • Phone: 541-706-5930
  • Fax: 541-706-5931
Mailing address:
  • Phone: 541-548-8131
  • Fax: 541-706-3765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG50497
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD166601
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: