MEDICARE: MR. JASON THOMAS WILLIAM TETZLAFF IDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1002X	Independent Duty Corpsman	2099	AZ
2	174400000X	Specialist		CA
3	171000000X	Military Health Care Provider	2099	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2099	OTHER	AZ	US NAVY

General Provider Information

NPI Number	:	1043247091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JASON THOMAS WILLIAM TETZLAFF IDC

Provider Business Mailing Address
First Line	:	4742 GAINARD WAY
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92124-2913
Country	:	US
Telephone Number	:	619-436-8538
Fax Number	:	619-437-2955

Provider Business Practice Location Address
First Line	:	3402 TARAWA RD
Second Line	:	SBT-12
City	:	SAN DIEGO
State	:	CA
Zip	:	92155-5176
Country	:	US
Telephone Number	:	619-437-5539
Fax Number	:	619-437-2955

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2006
Last Update Date	:	04/22/2008

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