Provider Demographics
NPI:1528550654
Name:JOHN DEITRICK MD CONSULTING, LLC
Entity Type:Organization
Organization Name:JOHN DEITRICK MD CONSULTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:DEITRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-241-5911
Mailing Address - Street 1:PO BOX 8987
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-0687
Mailing Address - Country:US
Mailing Address - Phone:804-241-5911
Mailing Address - Fax:
Practice Address - Street 1:173 WADSWORTH DR
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-4500
Practice Address - Country:US
Practice Address - Phone:804-674-5957
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-04
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010375982086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1457338741OtherTYPE 1 NPI