Provider Demographics
NPI:1043247091
Name:TETZLAFF, JASON THOMAS WILLIAM (IDC)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:THOMAS WILLIAM
Last Name:TETZLAFF
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4742 GAINARD WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-2913
Mailing Address - Country:US
Mailing Address - Phone:619-436-8538
Mailing Address - Fax:619-437-2955
Practice Address - Street 1:3402 TARAWA RD
Practice Address - Street 2:SBT-12
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5176
Practice Address - Country:US
Practice Address - Phone:619-437-5539
Practice Address - Fax:619-437-2955
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20991710I1002X
CA174400000X
CA2099171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No174400000XOther Service ProvidersSpecialist
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2099OtherUS NAVY