Provider Demographics
NPI:1447445879
Name:LISA DIETZ DO PLLC
Entity type:Organization
Organization Name:LISA DIETZ DO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-992-9975
Mailing Address - Street 1:6507 TOWN CENTER DR
Mailing Address - Street 2:STE A
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4826
Mailing Address - Country:US
Mailing Address - Phone:248-992-9975
Mailing Address - Fax:248-992-9143
Practice Address - Street 1:6507 TOWN CENTER DR
Practice Address - Street 2:STE A
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-4826
Practice Address - Country:US
Practice Address - Phone:248-992-9975
Practice Address - Fax:248-992-9143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0P26880Medicare PIN