Provider Demographics
NPI:1558581116
Name:DIETZ, MELISSA ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:ANN
Last Name:DIETZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 E 19TH ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5437
Mailing Address - Country:US
Mailing Address - Phone:918-749-1413
Mailing Address - Fax:918-749-0234
Practice Address - Street 1:1725 E 19TH ST
Practice Address - Street 2:SUITE 401
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5437
Practice Address - Country:US
Practice Address - Phone:918-749-1413
Practice Address - Fax:918-748-7511
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24521207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200125470AMedicaid
OK200567150AMedicaid
OK100747570AMedicaid
OK400522488Medicare PIN
OKDC3959Medicare PIN
OKP00827757Medicare PIN