Basic Information
| Provider Information | |||||||||
| NPI: | 1851426753 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIETZMAN | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | TODD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 135 S GIBSON ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544511622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157488100 | ||||||||
| FaxNumber: | 7158488199 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 SOUTH GIBSON STREET | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157488112 | ||||||||
| FaxNumber: | 7157488792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 07/10/2007 | ||||||||
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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 | 2255A2300X | 197-039 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.