Provider Demographics
NPI:1588733125
Name:TIEDEMAN, JAMES STUART
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:STUART
Last Name:TIEDEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 N MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-2344
Mailing Address - Country:US
Mailing Address - Phone:540-213-7720
Mailing Address - Fax:540-213-7481
Practice Address - Street 1:17 N MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2344
Practice Address - Country:US
Practice Address - Phone:540-213-7720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048613207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006324321Medicaid
VAC86781Medicare UPIN
VA006324321Medicaid