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General NPI Number Information
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NPI Number | 1346254141
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Entity Type | Individual
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Provider Name | JACK KENNETH DEITCHMAN MD
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Gender | Male
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Dates
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Enumeration Date | 07/28/2006
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Last Update Date | 03/05/2009
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Provider Practice Location Address
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Address Line | 140 LITTON DRIVE SUITE 110
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City | GRASS VALLEY
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State | CA
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Zip | 95945
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Country | US
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Telephone | 530-274-8483
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Fax | 530-271-2067
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Provider Business Mailing Address
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Address Line | 140 LITTON DRIVE SUITE 110
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City | GRASS VALLEY
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State | CA
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Zip | 95945
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Country | US
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Telephone | 530-274-8483
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Fax | 530-271-2067
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2083P0500X
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Taxonomy Name | Preventive Medicine/Occupational Environmental Medicine Physician
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License Number | G26297
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License Number State | CA
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