Provider Demographics
NPI:1639597636
Name:DIETRICH, KEVIN CLAYTON (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:CLAYTON
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2544
Mailing Address - Country:US
Mailing Address - Phone:309-662-7700
Mailing Address - Fax:
Practice Address - Street 1:13001 E. 17TH PLACE
Practice Address - Street 2:UNIVERSITY OF COLORADO SCHOOL OF MEDICINE GME
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2581
Practice Address - Country:US
Practice Address - Phone:303-724-2685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036159348207W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program