Healthcare Provider Details

I. General information

NPI: 1013448844
Provider Name (Legal Business Name): JASON EDWARD DIETZ MBBCHBAO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4720 VINETA AVE
LA CANADA CA
91011-2619
US

IV. Provider business mailing address

51 N 39TH ST
PHILADELPHIA PA
19104-2640
US

V. Phone/Fax

Practice location:
  • Phone: 818-306-6240
  • Fax:
Mailing address:
  • Phone: 215-662-9990
  • Fax: 215-243-3297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD470749
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: