Provider Demographics
NPI:1730139502
Name:TESSENDORF, TODD JASON (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:JASON
Last Name:TESSENDORF
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 1:1600 S 48TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-1275
Mailing Address - Country:US
Mailing Address - Phone:402-483-3333
Mailing Address - Fax:402-483-3297
Practice Address - Street 1:1600 S 48TH ST
Practice Address - Street 2:SUITE 600
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-1275
Practice Address - Country:US
Practice Address - Phone:402-483-3333
Practice Address - Fax:402-483-3297
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22234207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0762344Medicaid
KS200426260AMedicaid
MO204033609Medicaid
NE47084496100Medicaid
SD7720160Medicaid
NE277774Medicare PIN
MOM48F165Medicare PIN
MO204033609Medicaid
IA0762344Medicaid