Provider Demographics
NPI:1497759807
Name:DIETZ, BERNHARD ERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNHARD
Middle Name:ERIC
Last Name:DIETZ
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 1:116 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TN
Mailing Address - Zip Code:38340-2231
Mailing Address - Country:US
Mailing Address - Phone:731-989-0001
Mailing Address - Fax:731-520-0064
Practice Address - Street 1:116 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TN
Practice Address - Zip Code:38340-2231
Practice Address - Country:US
Practice Address - Phone:731-824-2400
Practice Address - Fax:731-824-0388
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27623207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3077257OtherBC/BS OF TENNESSEE
TN7864OtherTLC-MEMPHIS MANAGED CARE
TN3818356Medicaid
TN80121733OtherMETRAHEALTH
TN5572559OtherAETNA
3818356Medicare PIN
TN3077257OtherBC/BS OF TENNESSEE
TN80121733OtherMETRAHEALTH