Provider Demographics
NPI:1689435026
Name:DIETZEL, EBERHARDT ALAN
Entity Type:Individual
Prefix:MR
First Name:EBERHARDT
Middle Name:ALAN
Last Name:DIETZEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1829
Mailing Address - Country:US
Mailing Address - Phone:920-559-8808
Mailing Address - Fax:
Practice Address - Street 1:1006 QUINCY ST
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1829
Practice Address - Country:US
Practice Address - Phone:920-559-8808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer