Provider Demographics
NPI:1457338741
Name:DEITRICK, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:DEITRICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1051 JOHNSTON WILLIS DR
Mailing Address - Street 2:STE 200
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235
Mailing Address - Country:US
Mailing Address - Phone:804-320-2705
Mailing Address - Fax:804-330-2433
Practice Address - Street 1:1051 JOHNSTON WILLIS DR
Practice Address - Street 2:STE 200
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235
Practice Address - Country:US
Practice Address - Phone:804-320-2705
Practice Address - Fax:804-330-2433
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA01010375982086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1457338741Medicaid
VA7354380Medicaid
VA020000392Medicare ID - Type Unspecified
B06520Medicare UPIN