Healthcare Provider Details

I. General information

NPI: 1780417493
Provider Name (Legal Business Name): CONNOR DERYL DIETZ MD, FRCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 NELSON RISING LANE SUITE 190
SAN FRANCISCO CA
94158
US

IV. Provider business mailing address

675 NELSON RISING LANE SUITE 190
SAN FRANCISCO CA
94158
US

V. Phone/Fax

Practice location:
  • Phone: 415-866-6835
  • Fax:
Mailing address:
  • Phone: 415-866-6835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberA198459
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA198459
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: