MEDICARE: DR. GUS S WETZEL II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	R4095	MO
2	207Q00000X	Family Medicine Physician	R4095	MO

General Provider Information

NPI Number	:	1356318596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GUS S WETZEL II

Provider Business Mailing Address
First Line	:	1602 N 2ND ST
Second Line	:
City	:	CLINTON
State	:	MO
Zip	:	64735-1192
Country	:	US
Telephone Number	:	660-890-8023
Fax Number	:	660-890-8490

Provider Business Practice Location Address
First Line	:	1602 N 2ND ST
Second Line	:
City	:	CLINTON
State	:	MO
Zip	:	64735-1192
Country	:	US
Telephone Number	:	660-885-8171
Fax Number	:	660-890-8490

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2006
Last Update Date	:	11/16/2021

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