Provider Demographics
NPI:1063499127
Name:DIETERICH, STEVEN R (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:R
Last Name:DIETERICH
Suffix:
Gender:M
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:PO BOX 518
Mailing Address - Street 2:13 CHURCH RD
Mailing Address - City:EAST GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06026-0518
Mailing Address - Country:US
Mailing Address - Phone:860-653-4526
Mailing Address - Fax:860-653-5209
Practice Address - Street 1:13 CHURCH RD
Practice Address - Street 2:
Practice Address - City:EAST GRANBY
Practice Address - State:CT
Practice Address - Zip Code:06026-0518
Practice Address - Country:US
Practice Address - Phone:860-653-4526
Practice Address - Fax:860-653-5209
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT018693207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT140065OtherAETNA
CT001186931Medicaid
CT010018693CT01OtherBCBS
CT0104402OtherUNITED
CT018693OtherCT
CTHAP210OtherOXFORD
CT2085328005OtherCIGNA
CT0P0372OtherHEALTHNET
CT010018693CT01OtherBCBS
CT2085328005OtherCIGNA