Provider Demographics
NPI:1093710410
Name:DIETHELM, JAMES D (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:D
Last Name:DIETHELM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4235 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623
Mailing Address - Country:US
Mailing Address - Phone:419-473-3561
Mailing Address - Fax:419-473-0474
Practice Address - Street 1:7640 SYLVANIA AVENUE
Practice Address - Street 2:#100
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560
Practice Address - Country:US
Practice Address - Phone:419-473-2273
Practice Address - Fax:419-473-0474
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35041896207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0411969Medicaid
OH080164173OtherRAILROAD MEDICARE
OHH080980Medicare PIN
OH080164173OtherRAILROAD MEDICARE
OHC02410Medicare UPIN