Provider Demographics
NPI:1992992077
Name:DIETZ, ROBERT OWEN (DC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:OWEN
Last Name:DIETZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 NE BURNSIDE RD
Mailing Address - Street 2:SUITE 502
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-6722
Mailing Address - Country:US
Mailing Address - Phone:503-492-3910
Mailing Address - Fax:503-492-3905
Practice Address - Street 1:1217 NE BURNSIDE RD
Practice Address - Street 2:SUITE 502
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-6722
Practice Address - Country:US
Practice Address - Phone:503-492-3910
Practice Address - Fax:503-492-3905
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR273650111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA273650OtherMEDICAL LICENSE