MEDICARE: MR. CHARLES DAVID DIETZEN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	009627	TN
2	208D00000X	General Practice Physician	051638	GA

General Provider Information

NPI Number	:	1417964248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES DAVID DIETZEN MD

Provider Business Mailing Address
First Line	:	2621 CRESTWOOD DR
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37415-6321
Country	:	US
Telephone Number	:	423-266-3500
Fax Number	:

Provider Business Practice Location Address
First Line	:	4355 HIGHWAY 58
Second Line	:	SUITE 101
City	:	CHATTANOOGA
State	:	TN
Zip	:	37416-2939
Country	:	US
Telephone Number	:	423-892-4289
Fax Number	:	423-892-8301

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	07/08/2007

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