Provider Demographics
NPI:1366566499
Name:DIETZ, JONATHAN (DO)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:DIETZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 D ST
Mailing Address - Street 2:2
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3867
Mailing Address - Country:US
Mailing Address - Phone:415-459-7416
Mailing Address - Fax:
Practice Address - Street 1:540 D ST
Practice Address - Street 2:2
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3867
Practice Address - Country:US
Practice Address - Phone:415-459-7416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7626207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM09171981OtherSON'S BIRTH