Provider Demographics
NPI:1316348790
Name:DIETZGEN, MARK (NMD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DIETZGEN
Suffix:
Gender:M
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16515 S 40TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0558
Mailing Address - Country:US
Mailing Address - Phone:480-961-0760
Mailing Address - Fax:480-961-0761
Practice Address - Street 1:16515 S 40TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-0558
Practice Address - Country:US
Practice Address - Phone:480-961-0760
Practice Address - Fax:480-961-0761
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ01653175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath