Provider Demographics
NPI:1629232491
Name:DEETZ, CARL (MD/PHD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:
Last Name:DEETZ
Suffix:
Gender:M
Credentials:MD/PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 144333
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-4333
Mailing Address - Country:US
Mailing Address - Phone:407-422-9831
Mailing Address - Fax:
Practice Address - Street 1:11133 DUNN RD
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6163
Practice Address - Country:US
Practice Address - Phone:314-653-5630
Practice Address - Fax:314-653-4099
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO208017358207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400286920Medicare PIN
MO113910002Medicare PIN