Provider Demographics
NPI:1215943816
Name:DIETRICH, STEPHEN LESLIE (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LESLIE
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 1:15910 VENTURA BLVD
Mailing Address - Street 2:SUITE 1502
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2802
Mailing Address - Country:US
Mailing Address - Phone:818-728-9877
Mailing Address - Fax:
Practice Address - Street 1:15910 VENTURA BLVD
Practice Address - Street 2:SUITE 1502
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2802
Practice Address - Country:US
Practice Address - Phone:818-728-9877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50308207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G503080Medicaid
CABT895ZMedicare PIN
A51634Medicare UPIN
CA00G503080Medicaid
CAG50308AMedicare PIN
CABT895YMedicare PIN