Provider Demographics
NPI:1578210779
Name:WERNER IDIAQUEZ, DIETRICH (MD)
Entity Type:Individual
Prefix:DR
First Name:DIETRICH
Middle Name:
Last Name:WERNER IDIAQUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DIETRICH
Other - Middle Name:
Other - Last Name:WERNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:12902 USF MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-9416
Mailing Address - Country:US
Mailing Address - Phone:902-789-0518
Mailing Address - Fax:
Practice Address - Street 1:12902 USF MAGNOLIA DR DEPT OF
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:902-789-0518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL152109207ZH0000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology