Healthcare Provider Details

I. General information

NPI: 1033125174
Provider Name (Legal Business Name): STEVEN DEITCH DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 MAPLE AVENUE SUITE 3B
RED BANK NJ
07701
US

IV. Provider business mailing address

130 MAPLE AVENUE SUITE 3B
RED BANK NJ
07701
US

V. Phone/Fax

Practice location:
  • Phone: 732-747-2111
  • Fax: 732-530-1348
Mailing address:
  • Phone: 732-747-2111
  • Fax: 732-530-1348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number25MD00103800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: