Provider Demographics
NPI:1518917186
Name:DIETZ, ABRAHAM P (MD)
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:P
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 1:63 CAMP ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3006
Mailing Address - Country:US
Mailing Address - Phone:508-778-0203
Mailing Address - Fax:508-778-1155
Practice Address - Street 1:63 CAMP ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3006
Practice Address - Country:US
Practice Address - Phone:508-778-0203
Practice Address - Fax:508-778-1155
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA044541207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0138304Medicaid
MA0138304Medicaid
A59767Medicare UPIN