Provider Demographics
NPI:1760480834
Name:DIACZOK, BENJAMIN JOHN I (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOHN
Last Name:DIACZOK
Suffix:I
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:25925 TELEGRAPH RD
Mailing Address - Street 2:210
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-2518
Mailing Address - Country:US
Mailing Address - Phone:248-746-0342
Mailing Address - Fax:248-746-0369
Practice Address - Street 1:22255 GREENFIELD RD
Practice Address - Street 2:410
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3710
Practice Address - Country:US
Practice Address - Phone:248-849-2850
Practice Address - Fax:248-849-5751
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301050499207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301050499OtherCONTROLLED SUBSTANCE
MIBD01808142OtherFEDERAL DEA
MIBD01808142OtherFEDERAL DEA