Healthcare Provider Details

I. General information

NPI: 1336183011
Provider Name (Legal Business Name): KEVIN FRED DIETER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 05/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17876 SAINT CLAIR AVE
CLEVELAND OH
44110-2602
US

IV. Provider business mailing address

17876 SAINT CLAIR AVE
CLEVELAND OH
44110-2602
US

V. Phone/Fax

Practice location:
  • Phone: 216-383-2222
  • Fax:
Mailing address:
  • Phone: 216-383-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35053776
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number35.053776
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: