Provider Demographics
NPI:1194721506
Name:DIETRICH, SCOTT A (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
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 13579
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19612-3579
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1137 W PENN AVE
Practice Address - Street 2:
Practice Address - City:WOMELSDORF
Practice Address - State:PA
Practice Address - Zip Code:19567-9770
Practice Address - Country:US
Practice Address - Phone:610-589-2555
Practice Address - Fax:610-589-4940
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045097L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001280830Medicaid
F13007Medicare UPIN
PA001280830Medicaid