Provider Demographics
NPI:1982635165
Name:DIETZ, CHARLES ALBERT JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALBERT
Last Name:DIETZ
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:420 DELAWARE STREET SE
Mailing Address - Street 2:MMC 292 UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-626-3345
Mailing Address - Fax:
Practice Address - Street 1:516 DELAWARE STREET SE
Practice Address - Street 2:PWB 1ST FL CINIC 1D UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-273-6004
Practice Address - Fax:612-273-8459
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2012-05-01
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Provider Licenses
StateLicense IDTaxonomies
MN323792085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN16-09449OtherMEDICA CHOICE
MN868089OtherARAZ
MN1010250OtherPREFERRED ONE
MN17Y63DIOtherBCBS
MNHP22169OtherHEALTHPARTNERS
MT0058344Medicaid
MN16-02032OtherMEDICA PRIMARY
MN869302100OtherMN MA
MN105551OtherUCARE
MNHP22169OtherHEALTHPARTNERS
MN16-09449OtherMEDICA CHOICE
MNE63808Medicare UPIN