Provider Demographics
NPI:1720029259
Name:DIEDERICH, GARY D (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:D
Last Name:DIEDERICH
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 1:101 BOULDER POINT DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PLYMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03264
Mailing Address - Country:US
Mailing Address - Phone:603-536-4000
Mailing Address - Fax:603-536-4001
Practice Address - Street 1:859 LAKE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:NH
Practice Address - Zip Code:03222-4506
Practice Address - Country:US
Practice Address - Phone:603-744-6200
Practice Address - Fax:603-744-9024
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH6515207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH80000321Medicaid
NHRE4060OtherMEDICARE GROUP
NHRE4060OtherMEDICARE GROUP
NHB85860Medicare UPIN