Provider Demographics
NPI:1346269586
Name:GRENTZ, DIETMAR J (MD)
Entity Type:Individual
Prefix:DR
First Name:DIETMAR
Middle Name:J
Last Name:GRENTZ
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:7088 GREEN TIMBER CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-8193
Mailing Address - Country:US
Mailing Address - Phone:616-712-6436
Mailing Address - Fax:
Practice Address - Street 1:2725 AIRVIEW BLVD
Practice Address - Street 2:STE 105
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1803
Practice Address - Country:US
Practice Address - Phone:269-349-8386
Practice Address - Fax:269-349-8397
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN39564207Q00000X
MI4301069296207Q00000X
IL036069689207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
M97310016OtherMEDICARE