Provider Demographics
NPI:1639283344
Name:DIETZEK, CHARLES L (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:DIETZEK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 WHITE HORSE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-2157
Mailing Address - Country:US
Mailing Address - Phone:856-309-9777
Mailing Address - Fax:
Practice Address - Street 1:1101 WHITE HORSE RD
Practice Address - Street 2:SUITE C
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-2157
Practice Address - Country:US
Practice Address - Phone:856-309-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB467192086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0375209Medicaid
E52683Medicare UPIN
594065Medicare ID - Type Unspecified