Provider Demographics
NPI:1497218556
Name:DEITEL, CARLI MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:CARLI
Middle Name:MICHELLE
Last Name:DEITEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARLI
Other - Middle Name:MICHELLE
Other - Last Name:WITTGROVE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:34800 BOB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-1098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-532-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X, 390200000X
VA0101270523207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No171000000XOther Service ProvidersMilitary Health Care Provider
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program