Provider Demographics
NPI:1417927807
Name:DIETRICH, JOHN E (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1 SAINT VINCENT CIR
Mailing Address - Street 2:SUITE 160
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5405
Mailing Address - Country:US
Mailing Address - Phone:501-661-0037
Mailing Address - Fax:501-661-0038
Practice Address - Street 1:1 SAINT VINCENT CIR
Practice Address - Street 2:SUITE 160
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5405
Practice Address - Country:US
Practice Address - Phone:501-661-0037
Practice Address - Fax:501-661-0038
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2015-05-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ARE0736207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR129921001Medicaid
AR5K232Medicare ID - Type Unspecified
AR129921001Medicaid