Basic Information
| Provider Information | |||||||||
| NPI: | 1407275621 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIETLE | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | GLASS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GLASS | ||||||||
| OtherFirstName: | EMILY | ||||||||
| OtherMiddleName: | KATHARINE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2951 BALTIC AVE STE 410 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234513051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575722667 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6431 FANNIN STREET | ||||||||
| Address2: | SUITE MSB 3.151 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770305389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135005800 | ||||||||
| FaxNumber: | 7135005805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2014 | ||||||||
| LastUpdateDate: | 04/15/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.