Provider Demographics
NPI:1306831698
Name:DIETRICH, GREGORY DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:DEAN
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 WARNER DRIVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501
Mailing Address - Country:US
Mailing Address - Phone:208-743-3523
Mailing Address - Fax:208-746-8741
Practice Address - Street 1:320 WARNER DRIVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-743-3523
Practice Address - Fax:208-746-8741
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00034506207XS0117X
IDM7482207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID74823OtherBCI
ID805208800Medicaid
ID000010004322OtherREGENCE
WA8204851Medicaid
ID74823OtherBCI
ID200033093Medicare PIN
IDG42122Medicare UPIN
ID000010004322OtherREGENCE