MEDICARE: DR. MICHAEL MORGAN DIETCH III M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	58573	FL

General Provider Information

NPI Number	:	1043224538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL MORGAN DIETCH III M.D.

Provider Business Mailing Address
First Line	:	3875 S NOVA RD
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-4950
Country	:	US
Telephone Number	:	386-322-9244
Fax Number	:	386-788-9776

Provider Business Practice Location Address
First Line	:	3875 S NOVA RD
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-4950
Country	:	US
Telephone Number	:	386-322-9244
Fax Number	:	386-788-9776

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	08/20/2010

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