Basic Information
| Provider Information | |||||||||
| NPI: | 1093710410 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIETHELM | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4235 SECOR RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194733561 | ||||||||
| FaxNumber: | 4194730474 | ||||||||
| Practice Location | |||||||||
| Address1: | 7640 SYLVANIA AVENUE | ||||||||
| Address2: | #100 | ||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194732273 | ||||||||
| FaxNumber: | 4194730474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 05/01/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35041896 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0411969 | 05 | OH | MEDICAID | 080164173 | 01 | OH | RAILROAD MEDICARE | OTHER |