Provider Demographics
NPI:1285667816
Name:THIESZEN, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:THIESZEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 E MAGNOLIA ST
Mailing Address - Street 2:SUITE D199
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4796
Mailing Address - Country:US
Mailing Address - Phone:970-391-0572
Mailing Address - Fax:815-377-2580
Practice Address - Street 1:3528 GABEL RD
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-7307
Practice Address - Country:US
Practice Address - Phone:970-391-0572
Practice Address - Fax:815-377-2580
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47877-020207R00000X
CO47210207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO60427876Medicaid
MT12435OtherMT LIC
CO47210OtherCO LIC
CO47210OtherCO LIC
COCO304229Medicare PIN