Provider Demographics
NPI:1922192459
Name:SCHULTZE, DIETRICH WL (MD)
Entity Type:Individual
Prefix:
First Name:DIETRICH
Middle Name:WL
Last Name:SCHULTZE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11995 SINGLETREE LN STE 500
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5349
Mailing Address - Country:US
Mailing Address - Phone:952-595-1301
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:11995 SINGLETREE LN STE 500
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-5349
Practice Address - Country:US
Practice Address - Phone:952-595-1301
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1324092085R0202X
CT571772085R0204X
MA2692832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO48374717Medicaid
COC809549Medicare PIN
COC807702Medicare PIN
COC801370Medicare PIN
COH89176Medicare UPIN
COP00339406Medicare PIN
COC805336Medicare PIN
COC801369Medicare PIN
COC803975Medicare PIN