Healthcare Provider Details

I. General information

NPI: 1063405603
Provider Name (Legal Business Name): RAYMOND A DIETER III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 03/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 ALCOA HWY SUITE E310
KNOXVILLE TN
37920-2244
US

IV. Provider business mailing address

PO BOX 440547
NASHVILLE TN
37244-0547
US

V. Phone/Fax

Practice location:
  • Phone: 865-305-6955
  • Fax: 865-637-5216
Mailing address:
  • Phone: 865-670-6199
  • Fax: 865-670-6188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number021978
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: