Basic Information
| Provider Information | |||||||||
| NPI: | 1982635165 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIETZ | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | ALBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 DELAWARE STREET SE | ||||||||
| Address2: | MMC 292 UNIVERSITY OF MINNESOTA PHYSICIANS | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126263345 | ||||||||
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| Practice Location | |||||||||
| Address1: | 516 DELAWARE STREET SE | ||||||||
| Address2: | PWB 1ST FL CINIC 1D UNIVERSITY OF MINNESOTA PHYSICIANS | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122736004 | ||||||||
| FaxNumber: | 6122738459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| 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 | 2085R0202X | 32379 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 32379 | MN | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 16-09449 | 01 | MN | MEDICA CHOICE | OTHER | 868089 | 01 | MN | ARAZ | OTHER | 1010250 | 01 | MN | PREFERRED ONE | OTHER | 17Y63DI | 01 | MN | BCBS | OTHER | HP22169 | 01 | MN | HEALTHPARTNERS | OTHER | 0058344 | 05 | MT | MEDICAID | 16-02032 | 01 | MN | MEDICA PRIMARY | OTHER | 869302100 | 01 | MN | MN MA | OTHER | 105551 | 01 | MN | UCARE | OTHER |