MEDICARE: DR. JOHN NICHOLAS GIETZEN D.O.

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	207Q00000X	Family Medicine Physician	4158	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	Z178595	OTHER	AZ	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	F100847814	OTHER	WI	PTAN
2	1487274247	OTHER	IL	NPI

General Provider Information

NPI Number	:	1538178025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN NICHOLAS GIETZEN D.O.

Provider Business Mailing Address
First Line	:	W5491 WINDMILL RIDGE RD
Second Line	:
City	:	NEW GLARUS
State	:	WI
Zip	:	53574-9489
Country	:	US
Telephone Number	:	608-518-3654
Fax Number	:	928-277-4942

Provider Business Practice Location Address
First Line	:	W5491 WINDMILL RIDGE RD
Second Line	:
City	:	NEW GLARUS
State	:	WI
Zip	:	53574-9489
Country	:	US
Telephone Number	:	608-518-3654
Fax Number	:	928-277-4942

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

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	11/28/2022

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