Healthcare Provider Details

I. General information

NPI: 1639283344
Provider Name (Legal Business Name): CHARLES L DIETZEK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 WHITE HORSE RD SUITE C
VOORHEES NJ
08043-2157
US

IV. Provider business mailing address

1101 WHITE HORSE RD SUITE C
VOORHEES NJ
08043-2157
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMB46719
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: