Provider Demographics
NPI:1245288752
Name:DIETRICH, KENNETH ANTHONY (MD, MBA)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ANTHONY
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
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Mailing Address - Street 1:600 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541-9560
Mailing Address - Country:US
Mailing Address - Phone:360-346-2240
Mailing Address - Fax:360-346-2192
Practice Address - Street 1:600 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:WA
Practice Address - Zip Code:98541-9560
Practice Address - Country:US
Practice Address - Phone:360-346-2240
Practice Address - Fax:360-346-2192
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA271332080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine