Provider Demographics
NPI:1619925401
Name:DIETRICH, MARVIN LEROY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:LEROY
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18922 E TONTO VERDE DR
Mailing Address - Street 2:
Mailing Address - City:RIO VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85263-5200
Mailing Address - Country:US
Mailing Address - Phone:480-471-3426
Mailing Address - Fax:480-471-3428
Practice Address - Street 1:10503 W THUNDERBIRD BLVD
Practice Address - Street 2:#301
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3022
Practice Address - Country:US
Practice Address - Phone:623-974-3647
Practice Address - Fax:623-977-0310
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27044207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ11172652OtherCAQH UNIVERSAL PROVIDER #
NE11541OtherSTATE LICENSE
AZ6248578-004OtherCIGNA
AZ27044OtherSTATE LICENSE
AZAZ0885510OtherAZ BC/BS
AZAZ0885510OtherAZ BC/BS
AZ65001Medicare ID - Type Unspecified
AZ27044OtherSTATE LICENSE