Provider Demographics
NPI:1336259290
Name:DIETZE, PETER JR (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:DIETZE
Suffix:JR
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 1:10243 GENETIC CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-6310
Mailing Address - Country:US
Mailing Address - Phone:858-499-2702
Mailing Address - Fax:858-526-6113
Practice Address - Street 1:10243 GENETIC CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-6310
Practice Address - Country:US
Practice Address - Phone:858-499-2702
Practice Address - Fax:858-526-6113
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 79877207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G 798770Medicaid
G 55194Medicare UPIN
CA00G 798770Medicaid