Healthcare Provider Details

I. General information

NPI: 1790756385
Provider Name (Legal Business Name): CHARLES JOSEPH DIETZEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 RILEY HOSPITAL DR RI 3146
INDIANAPOLIS IN
46202-5109
US

IV. Provider business mailing address

PO BOX 1026
INDIANAPOLIS IN
46206-1026
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-2353
  • Fax: 317-944-2390
Mailing address:
  • Phone: 317-274-1201
  • Fax: 317-278-9905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number01036773A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: