Healthcare Provider Details

I. General information

NPI: 1497759807
Provider Name (Legal Business Name): BERNHARD ERIC DIETZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 W MAIN ST
HENDERSON TN
38340-2231
US

IV. Provider business mailing address

116 W MAIN ST
HENDERSON TN
38340-2231
US

V. Phone/Fax

Practice location:
  • Phone: 731-824-2400
  • Fax: 731-824-0388
Mailing address:
  • Phone: 731-989-0001
  • Fax: 731-520-0064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27623
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: