Healthcare Provider Details

I. General information

NPI: 1437489531
Provider Name (Legal Business Name): EDITH DIETZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2010
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 EASTERN AVE
BALTIMORE MD
21224-2735
US

IV. Provider business mailing address

4940 EASTERN AVE
BALTIMORE MD
21224-2735
US

V. Phone/Fax

Practice location:
  • Phone: 410-550-0967
  • Fax:
Mailing address:
  • Phone: 410-550-0967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0077487
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: