Healthcare Provider Details

I. General information

NPI: 1538178025
Provider Name (Legal Business Name): JOHN NICHOLAS GIETZEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W5491 WINDMILL RIDGE RD
NEW GLARUS WI
53574-9489
US

IV. Provider business mailing address

W5491 WINDMILL RIDGE RD
NEW GLARUS WI
53574-9489
US

V. Phone/Fax

Practice location:
  • Phone: 608-518-3654
  • Fax: 928-277-4942
Mailing address:
  • Phone: 608-518-3654
  • Fax: 928-277-4942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4158
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: