Provider Demographics
NPI:1336168533
Name:NIETZ, BRIAN C (PT DPT MTC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:C
Last Name:NIETZ
Suffix:
Gender:M
Credentials:PT DPT MTC
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 977
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78294
Mailing Address - Country:US
Mailing Address - Phone:210-572-6313
Mailing Address - Fax:210-545-9369
Practice Address - Street 1:19260 STONE OAK PKWY
Practice Address - Street 2:SUITE 107
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258
Practice Address - Country:US
Practice Address - Phone:210-545-9355
Practice Address - Fax:210-545-9369
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1147538225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T6241OtherBLUE CROSS BLUE SHIELD
TX8G5495Medicare ID - Type Unspecified