Provider Demographics
NPI:1942200126
Name:DIETRICH, MALCOLM HOWARD (DO)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:HOWARD
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17403-2632
Mailing Address - Country:US
Mailing Address - Phone:717-843-8051
Mailing Address - Fax:717-846-0721
Practice Address - Street 1:1777 5TH AVE
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-2632
Practice Address - Country:US
Practice Address - Phone:717-843-8051
Practice Address - Fax:717-846-0721
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS002279L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB99647Medicare UPIN