Provider Demographics
NPI:1952445140
Name:ETZWEILER, JOHN HENRY (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HENRY
Last Name:ETZWEILER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11402 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3447
Mailing Address - Country:US
Mailing Address - Phone:262-241-4647
Mailing Address - Fax:
Practice Address - Street 1:11402 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 105
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3447
Practice Address - Country:US
Practice Address - Phone:262-241-4647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1733-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI75395Medicare ID - Type Unspecified