Provider Demographics
NPI:1144223785
Name:DIETRICK, KEITH J (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:J
Last Name:DIETRICK
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:2585 SOUTH STATE ROAD 7
Mailing Address - Street 2:STE 110
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-9323
Mailing Address - Country:US
Mailing Address - Phone:561-795-8655
Mailing Address - Fax:561-795-3275
Practice Address - Street 1:2585 SOUTH STATE ROAD 7
Practice Address - Street 2:STE 110
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-9323
Practice Address - Country:US
Practice Address - Phone:561-795-8655
Practice Address - Fax:561-795-3275
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2015-08-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME85786208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8242ZMedicare UPIN
FLE8242WMedicare UPIN
FLH28740Medicare UPIN