Provider Demographics
NPI:1952689705
Name:KIETZMAN, TIMOTHY J (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:KIETZMAN
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 1:2015 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3152
Mailing Address - Country:US
Mailing Address - Phone:630-668-8250
Mailing Address - Fax:
Practice Address - Street 1:2015 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3152
Practice Address - Country:US
Practice Address - Phone:630-668-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-28
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-073602207W00000X
IL036.073602207WX0109X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0109XAllopathic & Osteopathic PhysiciansOphthalmologyNeuro-ophthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-073602Medicaid