Provider Demographics
NPI:1538189154
Name:GIETZEN, KEVIN L (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:L
Last Name:GIETZEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 CHARLEVOIX AVE
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-9701
Mailing Address - Country:US
Mailing Address - Phone:231-489-8151
Mailing Address - Fax:231-668-7794
Practice Address - Street 1:1114 CHARLEVOIX AVE
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-9701
Practice Address - Country:US
Practice Address - Phone:231-489-8151
Practice Address - Fax:231-668-7794
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013761207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0452410245OtherBLUE CROSS BLUE SHIELD
MI4523065Medicaid
MI4523065Medicaid
MIH91337Medicare UPIN