Provider Demographics
NPI:1225233307
Name:KIESEL, JOHN DAVID (DPT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:KIESEL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:1312 W ARCH HAVEN AVE STE E
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2088
Practice Address - Country:US
Practice Address - Phone:812-336-8406
Practice Address - Fax:812-336-8342
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60132052225100000X
IN05010388A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01062853OtherRR MEDICARE
WA1225233307Medicaid
OR500669289Medicaid
WAP01062853OtherRR MEDICARE
ORR173061Medicare PIN