Provider Demographics
NPI:1083603591
Name:DIETERICH, DAVID DANIEL (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:DANIEL
Last Name:DIETERICH
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 1:455 PINELLAS ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3356
Mailing Address - Country:US
Mailing Address - Phone:727-445-1992
Mailing Address - Fax:727-445-1993
Practice Address - Street 1:455 PINELLAS ST
Practice Address - Street 2:SUITE 400
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3356
Practice Address - Country:US
Practice Address - Phone:727-445-1991
Practice Address - Fax:727-445-1986
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL053669207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065988600Medicaid
82318XOtherMEDICARE PTAN
82318XOtherMEDICARE PTAN
E12046Medicare UPIN