Provider Demographics
NPI:1104877042
Name:DILTZ, ELMER F JR (DO)
Entity type:Individual
Prefix:
First Name:ELMER
Middle Name:F
Last Name:DILTZ
Suffix:JR
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 1:4254 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213
Mailing Address - Country:US
Mailing Address - Phone:614-235-9944
Mailing Address - Fax:614-235-9344
Practice Address - Street 1:4254 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213
Practice Address - Country:US
Practice Address - Phone:614-235-9944
Practice Address - Fax:614-235-9344
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003331207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0538574Medicaid
OH0538574Medicaid
D89782Medicare UPIN