Provider Demographics
NPI:1407977473
Name:DIETRICH, JORG (MD PHD)
Entity Type:Individual
Prefix:
First Name:JORG
Middle Name:
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:275 BEACON ST
Mailing Address - Street 2:APT 2A
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-1270
Mailing Address - Country:US
Mailing Address - Phone:617-722-3025
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT STREET
Practice Address - Street 2:YAWKEY CENTER 9E PAPPAS CENTER FOR NEUROONCOLOGY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-724-8770
Practice Address - Fax:617-724-8769
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2012-09-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA2252712084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology