Provider Demographics
NPI:1043303860
Name:JETZER, THOMAS CARL (MD MPH)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:CARL
Last Name:JETZER
Suffix:
Gender:M
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6515 BARRIE RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2305
Mailing Address - Country:US
Mailing Address - Phone:952-920-5663
Mailing Address - Fax:952-924-1659
Practice Address - Street 1:6515 BARRIE RD
Practice Address - Street 2:SUITE 150
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2305
Practice Address - Country:US
Practice Address - Phone:952-920-5663
Practice Address - Fax:952-924-1659
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN221722083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNF69634Medicare UPIN