Provider Demographics
NPI:1679936926
Name:DIETZ, STEPHANIE ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:ELIZABETH
Last Name:DIETZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 UNDERWOOD ST # MP80
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1110
Mailing Address - Country:US
Mailing Address - Phone:321-841-8727
Mailing Address - Fax:321-843-3386
Practice Address - Street 1:52 UNDERWOOD ST # MP80
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1110
Practice Address - Country:US
Practice Address - Phone:321-841-8727
Practice Address - Fax:321-843-3386
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME145042207R00000X
IL036-148661208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106049800Medicaid