Provider Demographics
NPI:1558127498
Name:DIETRICH, DAVID J
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8444 N 90TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4437
Mailing Address - Country:US
Mailing Address - Phone:602-248-8886
Mailing Address - Fax:602-854-0504
Practice Address - Street 1:4802 E BROADWAY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716-4141
Practice Address - Country:US
Practice Address - Phone:608-889-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY130796163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse