Healthcare Provider Details

I. General information

NPI: 1346384898
Provider Name (Legal Business Name): ADAM GEMMEL REID DIETZ MD.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2007
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19950 RINALDI ST
PORTER RANCH CA
91326-4141
US

IV. Provider business mailing address

PO BOX 9602
MISSION HILLS CA
91346-9602
US

V. Phone/Fax

Practice location:
  • Phone: 818-403-2460
  • Fax: 818-363-7362
Mailing address:
  • Phone: 818-837-5637
  • Fax: 818-837-5589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA105159
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: