# CHARLES L DIETZEK, DO, FACOS, PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1306905658
- **Authorized official:** MRS. SUSAN BERKOWITZ (BILLING MANAGER)
- **Authorized official phone:** (856) 309-9777

## Contact information

- **Practice address:** 1000 WHITE HORSE RD, SUITE 703, VOORHEES, NJ 08043-4406
- **Practice address phone:** (856) 309-9777
- **Practice address fax:** (856) 309-9774
- **Mailing address:** 1000 WHITE HORSE RD, SUITE 703, VOORHEES, NJ 08043-4406
- **Mailing address phone:** (856) 309-9777
- **Mailing address fax:** (856) 309-9774

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2086S0129X | Vascular Surgery Physician | — | NULL | Yes |
| 2086S0129X | Vascular Surgery Physician | — | — | Yes |

## Other

- **Enumeration date:** 12/06/2006
- **Last updated:** 02/05/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 0071641 | — | NJ |
| 01 | — | 3947376 | AETNA | — |
| 01 | — | 60017604 | HORIZON | — |