Healthcare Provider Details

I. General information

NPI: 1700992443
Provider Name (Legal Business Name): ANDREW CHARLES DIETZ MD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

3701 WILSHIRE BLVD SUITE 600
LOS ANGELES CA
90010-2804
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-2546
  • Fax: 323-361-8068
Mailing address:
  • Phone: 323-361-2337
  • Fax: 323-361-8491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberML20008449
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9008602-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA117303
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number50809
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number9008602-1205
License Number StateUT
# 6
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberA117303
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: