Provider Demographics
NPI:1528015914
Name:DIETRICK, DANIEL D (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:D
Last Name:DIETRICK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:25 CROSSROADS DR
Mailing Address - Street 2:STE 306
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117
Mailing Address - Country:US
Mailing Address - Phone:410-825-6310
Mailing Address - Fax:410-825-6320
Practice Address - Street 1:8322 BELLONA AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2012
Practice Address - Country:US
Practice Address - Phone:410-825-6310
Practice Address - Fax:410-825-6320
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2014-04-23
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Provider Licenses
StateLicense IDTaxonomies
MDD0045331208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE57835Medicare UPIN
MD731LO190Medicare PIN