Provider Demographics
NPI:1043224538
Name:DIETCH III, MICHAEL MORGAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MORGAN
Last Name:DIETCH III
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3875 S NOVA RD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4950
Mailing Address - Country:US
Mailing Address - Phone:386-322-9244
Mailing Address - Fax:386-788-9776
Practice Address - Street 1:3875 S NOVA RD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4950
Practice Address - Country:US
Practice Address - Phone:386-322-9244
Practice Address - Fax:386-788-9776
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL58573207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12907Medicare ID - Type Unspecified
FLE99007Medicare UPIN