Provider Demographics
NPI:1992703706
Name:GIESEKE, TIMOTHY LOUIS (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LOUIS
Last Name:GIESEKE
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 1:3536 MENDOCINO AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-575-6049
Mailing Address - Fax:707-546-2188
Practice Address - Street 1:3536 MENDOCINO AVE
Practice Address - Street 2:300
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3634
Practice Address - Country:US
Practice Address - Phone:707-546-2180
Practice Address - Fax:707-546-2188
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34398207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G343980Medicaid
CAP00602516OtherRAILDROAD MEDICARE
CA00G343980OtherBLUE SHIELD OF CALIFORNIA
CA00G343981Medicare PIN
CAEZ122ZMedicare PIN
CA00G343982Medicare PIN
CAP00602516OtherRAILDROAD MEDICARE