Healthcare Provider Details

I. General information

NPI: 1467494393
Provider Name (Legal Business Name): DAMIAN D. DIETER D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 10/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 PORTAGE AVE
SOUTH BEND IN
46616-1740
US

IV. Provider business mailing address

1608 PORTAGE AVE
SOUTH BEND IN
46616-1740
US

V. Phone/Fax

Practice location:
  • Phone: 574-233-2966
  • Fax: 574-233-2995
Mailing address:
  • Phone: 574-233-2966
  • Fax: 574-233-2995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07000803
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000803
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: