Healthcare Provider Details

I. General information

NPI: 1992703706
Provider Name (Legal Business Name): TIMOTHY LOUIS GIESEKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 02/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3536 MENDOCINO AVE 300
SANTA ROSA CA
95403-3634
US

IV. Provider business mailing address

3536 MENDOCINO AVE STE 200
SANTA ROSA CA
95403-3634
US

V. Phone/Fax

Practice location:
  • Phone: 707-546-2180
  • Fax: 707-546-2188
Mailing address:
  • Phone: 707-575-6049
  • Fax: 707-546-2188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG34398
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: