Provider Demographics
NPI:1154456374
Name:DIEDERICH, GINETTE DREYFUSS- (MD)
Entity Type:Individual
Prefix:DR
First Name:GINETTE
Middle Name:DREYFUSS-
Last Name:DIEDERICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GINETTE
Other - Middle Name:DREYFUSS-
Other - Last Name:DIEDERICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD,
Mailing Address - Street 1:10125 SW 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-2005
Mailing Address - Country:US
Mailing Address - Phone:305-663-0565
Mailing Address - Fax:305-663-0565
Practice Address - Street 1:1469 NW 36TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-5557
Practice Address - Country:US
Practice Address - Phone:305-635-7444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00443282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL96478Medicare ID - Type UnspecifiedPROVIDER NUMBER
FLD78997Medicare UPIN