Provider Demographics
NPI:1558468462
Name:DIETZ, DANIELLE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:MARIE
Last Name:DIETZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1138 LEXINGTON RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9672
Mailing Address - Country:US
Mailing Address - Phone:502-570-3778
Mailing Address - Fax:502-570-3779
Practice Address - Street 1:1138 LEXINGTON RD
Practice Address - Street 2:SUITE 230
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9672
Practice Address - Country:US
Practice Address - Phone:502-570-3778
Practice Address - Fax:502-570-3779
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KYTP770208600000X
KY40300208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100003310Medicaid
KY7100003310Medicaid
I66960Medicare UPIN