Healthcare Provider Details

I. General information

NPI: 1093710410
Provider Name (Legal Business Name): JAMES D DIETHELM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7640 SYLVANIA AVENUE #100
SYLVANIA OH
43560
US

IV. Provider business mailing address

4235 SECOR RD
TOLEDO OH
43623
US

V. Phone/Fax

Practice location:
  • Phone: 419-473-2273
  • Fax: 419-473-0474
Mailing address:
  • Phone: 419-473-3561
  • Fax: 419-473-0474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35041896
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: