Provider Demographics
NPI:1386634749
Name:DEITCH, JEFFREY S (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:S
Last Name:DEITCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:37450 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-3503
Mailing Address - Country:US
Mailing Address - Phone:586-979-5100
Mailing Address - Fax:586-979-6198
Practice Address - Street 1:37450 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-3503
Practice Address - Country:US
Practice Address - Phone:586-979-5100
Practice Address - Fax:586-979-6198
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E50113Medicare UPIN
MIE06168005Medicare ID - Type Unspecified