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General NPI Number Information
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NPI Number | 1376730069
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Entity Type | Individual
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Provider Name | JASON PAUL DIETERLE DO
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Gender | Male
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Dates
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Enumeration Date | 09/26/2007
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Last Update Date | 09/04/2024
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Provider Practice Location Address
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Address Line | 5715 MEMORIAL AVE N
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City | OAK PARK HEIGHTS
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State | MN
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Zip | 55082-1093
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Country | US
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Telephone | 651-439-8807
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Fax | 651-439-0232
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Provider Business Mailing Address
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Address Line | 3500 AMERICAN BLVD W STE 300
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City | BLOOMINGTON
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State | MN
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Zip | 55431-4442
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Country | US
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Telephone | 952-512-5600
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Fax |
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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 | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 51694
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 52724-21
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 207XX0005X
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Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
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License Number | 52724-21
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License Number State | WI
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Taxonomy #4
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Taxonomy Code | 207XX0005X
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Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
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License Number | 51694
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License Number State | MN
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