Provider Demographics
NPI:1669790119
Name:DIETRICH, MARTIN FREDERIK (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:FREDERIK
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 HARVIN WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3229
Mailing Address - Country:US
Mailing Address - Phone:321-636-2111
Mailing Address - Fax:321-636-7180
Practice Address - Street 1:1048 HARVIN WAY
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3229
Practice Address - Country:US
Practice Address - Phone:321-636-2111
Practice Address - Fax:321-636-7180
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-07
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME128710207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018189900Medicaid