Provider Demographics
NPI:1740287614
Name:GOETSCH, NICHOLAS J (DO)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:GOETSCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5401
Mailing Address - Country:US
Mailing Address - Phone:319-272-8000
Mailing Address - Fax:
Practice Address - Street 1:3421 W 9TH ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5401
Practice Address - Country:US
Practice Address - Phone:319-272-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3649207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1740287614Medicaid
IAP00469847OtherRR MEDICARE
IA0456830Medicaid
IAI20723Medicare PIN