Provider Demographics
NPI:1134160435
Name:DIETZEK, ALAN MERRILL (MD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:MERRILL
Last Name:DIETZEK
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 1:331 NEWMAN SPRINGS RD STE 220
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-5792
Mailing Address - Country:US
Mailing Address - Phone:732-807-0877
Mailing Address - Fax:201-751-1680
Practice Address - Street 1:67 SAND PIT RD
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4032
Practice Address - Country:US
Practice Address - Phone:203-798-6986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA094136002086S0129X
CT0388452086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2372975OtherAETNA US HEALTHCARE
CT830396OtherUNITED HEALTHCARE
CT0V7532OtherHEALTH NET
CT038845OtherCONNECTICARE
CT810160110OtherPHCS
CT8897122OtherCIGNA
CTAS1058OtherOXFORD
CT1388455Medicaid
CTP00230453OtherRAILROAD MEDICARE
CTE62525Medicare UPIN
CT1388455Medicaid