Provider Demographics
NPI:1952581886
Name:DIETZ, CHRISTOPHER MARK (DO)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:MARK
Last Name:DIETZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 758963
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-8963
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:804-217-7991
Practice Address - Street 1:12 N THOMPSON ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23221-2718
Practice Address - Country:US
Practice Address - Phone:804-359-1337
Practice Address - Fax:804-358-9861
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS10235207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV3705AMedicare PIN