Provider Demographics
NPI:1023057858
Name:DEATRICH, DYLAN (MD)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:DEATRICH
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 1:343 E ROY FURMAN HWY
Mailing Address - Street 2:
Mailing Address - City:WAYNESBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15370-8084
Mailing Address - Country:US
Mailing Address - Phone:724-627-8080
Mailing Address - Fax:724-852-7510
Practice Address - Street 1:343 E ROY FURMAN HWY
Practice Address - Street 2:
Practice Address - City:WAYNESBURG
Practice Address - State:PA
Practice Address - Zip Code:15370-8084
Practice Address - Country:US
Practice Address - Phone:724-627-8080
Practice Address - Fax:724-852-7510
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD431647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I49068Medicare UPIN
PA098028Medicare PIN