Provider Demographics
NPI:1568465862
Name:DEETZ, DAVID L (DPM)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:DEETZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 S ALAMEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-2928
Mailing Address - Country:US
Mailing Address - Phone:575-523-8566
Mailing Address - Fax:575-525-2065
Practice Address - Street 1:710 S ALAMEDA BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2928
Practice Address - Country:US
Practice Address - Phone:575-523-8566
Practice Address - Fax:575-525-2065
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2008-05-14
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
NMNM142213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54072Medicaid
NMNM035303OtherBLUE CROSS BLUE SHIELD
NM54072Medicaid
NMT12971Medicare UPIN