Provider Demographics
NPI:1720183650
Name:DIETERICH, FREDERICK WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:WILLIAM
Last Name:DIETERICH
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 1:16671 YORBA LINDA BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-2025
Mailing Address - Country:US
Mailing Address - Phone:714-996-3700
Mailing Address - Fax:714-993-5897
Practice Address - Street 1:1000 VALLE TERRACE
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92064
Practice Address - Country:US
Practice Address - Phone:760-631-5000
Practice Address - Fax:760-414-3892
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGO41537207V00000X
CAG041537207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA48602Medicare UPIN
CAG41537Medicare ID - Type Unspecified