| Doctor Name: | MR. CHARLES DAVID DIETZEN |
| NPI Number: | 1417964248 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MD |
| License Number: | 051638 |
| Business Practice Address: | 4355 Highway 58 Suite 101 Chattanooga, TN - 374162939 |
| Business Phone Number: | 4238924289 |
| Business Fax Number: | 4238928301 |
| Mailing Address: | 2621 Crestwood Dr, CHATTANOOGA |
| State: | TN |
| Postal Code: | 374156321 |
| Phone Number: | 4232663500 |
| Fax Number: | |
| NPI Enumeration Date: | 08/02/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 051638 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | GA |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |