Provider Demographics
NPI:1952328734
Name:DIETRICH, PETER A (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:A
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 1:777 MOUNT PHILO RD
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482-6350
Mailing Address - Country:US
Mailing Address - Phone:802-847-3592
Mailing Address - Fax:802-847-4822
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:DEPT. OF RADIOLOGY
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-3592
Practice Address - Fax:802-847-4822
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00046522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT4754Medicaid
VTB85607Medicare UPIN
VTDIVT4754Medicare ID - Type Unspecified