Provider Demographics
NPI:1912934761
Name:DIETZEL, DOUGLAS PAUL (DO)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:PAUL
Last Name:DIETZEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD # A201
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-884-2676
Mailing Address - Fax:517-432-3928
Practice Address - Street 1:4660 S HAGADORN RD
Practice Address - Street 2:SUITE 420
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5376
Practice Address - Country:US
Practice Address - Phone:517-884-6100
Practice Address - Fax:517-884-6233
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011314207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3379305Medicaid
MI1912934761Medicaid
MI3379305Medicaid
MI0C36088Medicare PIN
MIOC36093Medicare PIN
MI0C36093005Medicare PIN