Provider Demographics
NPI:1639154263
Name:GIETZEN, BRIAN T (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:T
Last Name:GIETZEN
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 1:1460 WALTON BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-1768
Mailing Address - Country:US
Mailing Address - Phone:248-650-1800
Mailing Address - Fax:248-650-1856
Practice Address - Street 1:1460 WALTON BLVD
Practice Address - Street 2:STE 200
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1768
Practice Address - Country:US
Practice Address - Phone:248-650-1800
Practice Address - Fax:248-650-1856
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070159207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H51538Medicare UPIN
OP22110Medicare ID - Type Unspecified