Provider Demographics
NPI:1417964248
Name:DIETZEN, CHARLES DAVID (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DAVID
Last Name:DIETZEN
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 1:2621 CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37415-6321
Mailing Address - Country:US
Mailing Address - Phone:423-266-3500
Mailing Address - Fax:
Practice Address - Street 1:4355 HIGHWAY 58
Practice Address - Street 2:SUITE 101
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37416-2939
Practice Address - Country:US
Practice Address - Phone:423-892-4289
Practice Address - Fax:423-892-8301
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN009627208D00000X
GA051638208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
B63029Medicare UPIN