Provider Demographics
NPI:1528126067
Name:DIETER, ROBERT SEAN (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:SEAN
Last Name:DIETER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S FIRST AVE
Mailing Address - Street 2:(15750 MARIAN DR., HOMER GLEN, IL. 60491)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-645-3400
Mailing Address - Fax:708-216-8795
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:(15750 MARIAN DR., HOMER GLEN, IL. 60491)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-645-3400
Practice Address - Fax:708-216-8795
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099366207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK23219OtherMEDICARE
ILK23219OtherMEDICARE
ILK23220Medicare ID - Type Unspecified