Provider Demographics
NPI:1053654608
Name:DIETRICH, TIMOTHY JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 CLUB MANOR DRIVE
Mailing Address - Street 2:, SUITE 2
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-7401
Mailing Address - Country:US
Mailing Address - Phone:501-851-7402
Mailing Address - Fax:501-851-4753
Practice Address - Street 1:1705 CLUB MANOR DRIVE,
Practice Address - Street 2:SUITE 2
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113-7401
Practice Address - Country:US
Practice Address - Phone:501-851-7402
Practice Address - Fax:501-851-4753
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3259207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program