Healthcare Provider Details

I. General information

NPI: 1447226717
Provider Name (Legal Business Name): JOHN R DIETLEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 10/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6886 HOLLOW MILL DR
SALT LAKE CITY UT
84121-3322
US

IV. Provider business mailing address

PO BOX 712270
SALT LAKE CITY UT
84171-2270
US

V. Phone/Fax

Practice location:
  • Phone: 801-944-0095
  • Fax:
Mailing address:
  • Phone: 801-944-0095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number83-169963-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: