Provider Demographics
NPI:1073757969
Name:FW DIETERICH MD INC
Entity Type:Organization
Organization Name:FW DIETERICH MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:W
Authorized Official - Last Name:DIETERICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-572-1921
Mailing Address - Street 1:1275 N. ROSE DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-3945
Mailing Address - Country:US
Mailing Address - Phone:714-572-1921
Mailing Address - Fax:714-572-8334
Practice Address - Street 1:1275 N. ROSE DR
Practice Address - Street 2:SUITE 106
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-3945
Practice Address - Country:US
Practice Address - Phone:714-572-1921
Practice Address - Fax:714-572-8334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-23
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41537207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A48602Medicare UPIN