Provider Demographics
NPI:1487672945
Name:DIETZ, JILL R (MD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:R
Last Name:DIETZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-1617
Mailing Address - Country:US
Mailing Address - Phone:516-663-1950
Mailing Address - Fax:516-741-3562
Practice Address - Street 1:1111 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-1617
Practice Address - Country:US
Practice Address - Phone:516-663-1950
Practice Address - Fax:516-741-3562
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD474935208600000X
NY333332208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
15405815OtherCAQH
OH2115419Medicaid
G83659Medicare UPIN
OHH378631Medicare PIN