Provider Demographics
NPI:1316928351
Name:TILSTRA, DAVID J (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:TILSTRA
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 1:1900 CENTRACARE CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-5000
Mailing Address - Country:US
Mailing Address - Phone:320-654-3630
Mailing Address - Fax:320-654-3657
Practice Address - Street 1:1900 CENTRACARE CIR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-5000
Practice Address - Country:US
Practice Address - Phone:320-654-3630
Practice Address - Fax:320-654-3657
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37920207SG0201X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1008055OtherPREFERRED ONE
763003OtherARAZ GROUP AMERICAS PPO
51A44TIOtherBLUE CROSS BLUE SHIELD
1200086OtherMEDICA HEALTH PLANS
2089340OtherFIRST HEALTH PLAN
7713350OtherSOUTH DAKOTA MA
HP25528OtherHEALTH PARTNERS
074814500OtherMEDICAL ASSISTANCE
110417OtherUCARE
G01924Medicare UPIN
2089340OtherFIRST HEALTH PLAN