Healthcare Provider Details

I. General information

NPI: 1306905658
Provider Name (Legal Business Name): CHARLES L DIETZEK, DO, FACOS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 02/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WHITE HORSE RD SUITE 703
VOORHEES NJ
08043-4406
US

IV. Provider business mailing address

1000 WHITE HORSE RD SUITE 703
VOORHEES NJ
08043-4406
US

V. Phone/Fax

Practice location:
  • Phone: 856-309-9777
  • Fax: 856-309-9774
Mailing address:
  • Phone: 856-309-9777
  • Fax: 856-309-9774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. SUSAN BERKOWITZ
Title or Position: BILLING MANAGER
Credential:
Phone: 856-309-9777