Provider Demographics
NPI:1174559124
Name:DIETZ, ROBERT REX (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:REX
Last Name:DIETZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:R
Other - Middle Name:REX
Other - Last Name:DIETZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4793 US HIGHWAY 3
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106-9676
Mailing Address - Country:US
Mailing Address - Phone:406-237-5862
Mailing Address - Fax:406-238-6068
Practice Address - Street 1:2900 12TH AVE N
Practice Address - Street 2:SUITE 210W
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-7506
Practice Address - Country:US
Practice Address - Phone:406-237-5862
Practice Address - Fax:406-238-6068
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT72772085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY101253300Medicaid
MT99125Medicaid
MT6031OtherBLUE CROSS BLUE SHIELD
MT99125Medicaid
WY101253300Medicaid