Provider Demographics
NPI:1760480834
Name:DIACZOK, BENJAMIN JOHN I (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOHN
Last Name:DIACZOK
Suffix:I
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR # J2000
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:44428 WOODWARD AVE STE 102
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5009
Practice Address - Country:US
Practice Address - Phone:248-858-3126
Practice Address - Fax:248-858-6499
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050499207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI348812110Medicaid
MI4301050499OtherCONTROLLED SUBSTANCE
MIBD01808142OtherFEDERAL DEA