Provider Demographics
NPI:1952397036
Name:DIETRICH, WILLIAM G (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:G
Last Name:DIETRICH
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:PO BOX 863026
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3026
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:1 SHIRCLIFF WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4748
Practice Address - Country:US
Practice Address - Phone:989-356-7390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55253207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL930051064OtherRRMCR
FL12806OtherBCBS
FL055296800Medicaid
FL12806OtherBCBS
FL12806XMedicare ID - Type UnspecifiedMEDICARE