Provider Demographics
NPI:1265534143
Name:DEITRICK, GEORGE (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:DEITRICK
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 1:17 KENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-3034
Mailing Address - Country:US
Mailing Address - Phone:516-248-1420
Mailing Address - Fax:
Practice Address - Street 1:130 W KINGSBRIDGE RD
Practice Address - Street 2:JAMES J . PETERS VA MEDICAL CENTER
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-3904
Practice Address - Country:US
Practice Address - Phone:718-584-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188018-12081P0004X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery