Provider Demographics
NPI:1194714774
Name:TIEDE, JEFFREY MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:TIEDE
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:UNIT 33100 BOX LANDSTUHL
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180-3100
Mailing Address - Country:US
Mailing Address - Phone:314-590-4620
Mailing Address - Fax:
Practice Address - Street 1:UNIT 33100 BOX LANDSTUHL
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180-3100
Practice Address - Country:US
Practice Address - Phone:314-590-4620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007032264207LP2900X
FLME88152207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL71413OtherBLUECROSS/BLUESHIELD
FL71413OtherBLUECROSS/BLUESHIELD
FLH23290Medicare UPIN