Provider Demographics
NPI:1588451140
Name:KIETZMAN, ALEXANDER THOMAS
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:THOMAS
Last Name:KIETZMAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 BRIGHTON CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-7000
Mailing Address - Country:US
Mailing Address - Phone:682-216-6414
Mailing Address - Fax:
Practice Address - Street 1:5323 HARRY HINES BLVD STOP 7200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7709
Practice Address - Country:US
Practice Address - Phone:214-648-3433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program