Provider Demographics
NPI:1073952297
Name:DIETRICH, BENJAMIN DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:DAVID
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48740-9693
Mailing Address - Country:US
Mailing Address - Phone:989-724-7440
Mailing Address - Fax:989-724-7531
Practice Address - Street 1:300 N STATE ST
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:MI
Practice Address - Zip Code:48740-9693
Practice Address - Country:US
Practice Address - Phone:989-724-7440
Practice Address - Fax:989-724-7531
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004764152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Z10008OtherBLUE CROSS BLUE SHIELD PIN
MIM85120004Medicare PIN