Provider Demographics
NPI:1285922625
Name:TEGTMEIER, JOHN DAVID (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:TEGTMEIER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD # A109F
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-884-2976
Mailing Address - Fax:517-432-3928
Practice Address - Street 1:4660 S HAGADORN RD STE 520
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6804
Practice Address - Country:US
Practice Address - Phone:517-884-8701
Practice Address - Fax:517-884-8787
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010194992081N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1285922625Medicaid
MI0C36082180Medicare PIN