Provider Demographics
NPI:1063403905
Name:DIETRICH, CHRISTOPHER T (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:T
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 6850
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-6850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:605-341-7062
Practice Address - Street 1:4141 5TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-6021
Practice Address - Country:US
Practice Address - Phone:605-341-1414
Practice Address - Fax:605-341-7062
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5661208VP0014X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0100322OtherWELLMARK BCBS
SD41194500700OtherNEBRASKA MEDICAID
SD5661OtherDAKOTACARE
SD115322600OtherWYOMING MEDICAID
SD121334200OtherWYOMING MEDICAID
SD0122767OtherMEDICA
SD0006332OtherWELLMARK BCBS
SD1063403905Medicaid
SD45827OtherSANFORD HEALTH PLAN
SD0122767OtherMEDICA
SD5661OtherDAKOTACARE
SD1063403905Medicaid