Healthcare Provider Details

I. General information

NPI: 1366566499
Provider Name (Legal Business Name): JONATHAN DIETZ D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 D ST 2
SAN RAFAEL CA
94901-3867
US

IV. Provider business mailing address

540 D ST 2
SAN RAFAEL CA
94901-3867
US

V. Phone/Fax

Practice location:
  • Phone: 415-459-7416
  • Fax:
Mailing address:
  • Phone: 415-459-7416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number20A7626
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: