Provider Demographics
NPI:1821024050
Name:RIETZ, JOHN T (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:RIETZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 19TH AVE
Mailing Address - Street 2:PO BOX 1104
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4005
Mailing Address - Country:US
Mailing Address - Phone:208-746-3626
Mailing Address - Fax:208-746-1636
Practice Address - Street 1:1616 19TH AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4005
Practice Address - Country:US
Practice Address - Phone:208-746-3626
Practice Address - Fax:208-746-1636
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-831152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2012219Medicaid
ID004322700Medicaid
WA2012219Medicaid
ID004322700Medicaid