Provider Demographics
NPI:1427147396
Name:DIETZ, KATHRYN E (MD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:E
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 1:2418 W INDIAN TRL STE F
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-1590
Mailing Address - Country:US
Mailing Address - Phone:630-907-0578
Mailing Address - Fax:
Practice Address - Street 1:20 PIDGEON HILL DR STE 208
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-6134
Practice Address - Country:US
Practice Address - Phone:703-539-6059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101053428207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704623Medicaid
MIG60743Medicare UPIN
MI4704623Medicaid