Provider Demographics
NPI:1124103528
Name:DIETRICK, JOHN III (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DIETRICK
Suffix:III
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 1:1904 W MORRISON AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2831
Mailing Address - Country:US
Mailing Address - Phone:813-258-9864
Mailing Address - Fax:
Practice Address - Street 1:3000 MEDICAL PARK DR
Practice Address - Street 2:SUITE 330
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4680
Practice Address - Country:US
Practice Address - Phone:813-971-2470
Practice Address - Fax:813-971-2491
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88224208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273011100Medicaid
FL71357YMedicare ID - Type UnspecifiedPROVIDER NUMBER
FL273011100Medicaid