Provider Demographics
NPI:1699734756
Name:DIETLIN, KATHY M (MD)
Entity type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:M
Last Name:DIETLIN
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:49 STATE ROAD
Mailing Address - Street 2:WATUPPA BUILDING SUITE 203
Mailing Address - City:NORTH DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-3300
Mailing Address - Country:US
Mailing Address - Phone:508-994-0120
Mailing Address - Fax:508-996-9636
Practice Address - Street 1:49 STATE ROAD
Practice Address - Street 2:WATUPPA BUILDING SUITE 203
Practice Address - City:NORTH DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-3300
Practice Address - Country:US
Practice Address - Phone:508-994-0120
Practice Address - Fax:508-996-9636
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA78175207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3118061Medicaid
MUJ30170Medicare ID - Type Unspecified
MA3118061Medicaid