Basic Information
| Provider Information | |||||||||
| NPI: | 1760480834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIACZOK | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | I | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25925 TELEGRAPH RD | ||||||||
| Address2: | 210 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480342518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487460342 | ||||||||
| FaxNumber: | 2487460369 | ||||||||
| Practice Location | |||||||||
| Address1: | 22255 GREENFIELD RD | ||||||||
| Address2: | 410 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480753710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488492850 | ||||||||
| FaxNumber: | 2488495751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301050499 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4301050499 | 01 | MI | CONTROLLED SUBSTANCE | OTHER | BD01808142 | 01 | MI | FEDERAL DEA | OTHER |