Provider Demographics
NPI:1629013685
Name:GOLTZ, GRETCHEN C (DO)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:C
Last Name:GOLTZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1848
Mailing Address - Country:US
Mailing Address - Phone:866-611-1512
Mailing Address - Fax:231-728-4789
Practice Address - Street 1:3535 PARK ST
Practice Address - Street 2:SUITE 110
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-3736
Practice Address - Country:US
Practice Address - Phone:231-672-3155
Practice Address - Fax:231-672-1535
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013344207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4879110Medicaid
MI4879110Medicaid