Basic Information
| Provider Information | |||||||||
| NPI: | 1316928351 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TILSTRA | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CENTRACARE CIR | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543630 | ||||||||
| FaxNumber: | 3206543657 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 CENTRACARE CIR | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543630 | ||||||||
| FaxNumber: | 3206543657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 12/13/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207SG0201X | 37920 | MN | Y | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | 208000000X | 37920 | MN | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1008055 | 01 | PREFERRED ONE | OTHER | 763003 | 01 | ARAZ GROUP AMERICAS PPO | OTHER | 51A44TI | 01 | BLUE CROSS BLUE SHIELD | OTHER | 1200086 | 01 | MEDICA HEALTH PLANS | OTHER | 2089340 | 01 | FIRST HEALTH PLAN | OTHER | 7713350 | 01 | SOUTH DAKOTA MA | OTHER | HP25528 | 01 | HEALTH PARTNERS | OTHER | 074814500 | 01 | MEDICAL ASSISTANCE | OTHER | 110417 | 01 | UCARE | OTHER |