Provider Demographics
NPI:1174518039
Name:GRIESHABER, GORDON J (MD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:J
Last Name:GRIESHABER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:104 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MINERAL POINT
Mailing Address - State:WI
Mailing Address - Zip Code:53565-1289
Mailing Address - Country:US
Mailing Address - Phone:608-987-2346
Mailing Address - Fax:608-987-2490
Practice Address - Street 1:104 HIGH ST
Practice Address - Street 2:
Practice Address - City:MINERAL POINT
Practice Address - State:WI
Practice Address - Zip Code:53565-1289
Practice Address - Country:US
Practice Address - Phone:608-987-2346
Practice Address - Fax:608-987-2490
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI34127207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31918300Medicaid
WIF55299Medicare UPIN
WI31918300Medicaid