Provider Demographics
NPI:1467475202
Name:DIETERLE, JOSEPH ANTHONY JR (DO)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ANTHONY
Last Name:DIETERLE
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:BOX 532
Mailing Address - Street 2:112 FIRST ST.
Mailing Address - City:OXFORD
Mailing Address - State:MD
Mailing Address - Zip Code:21654-0532
Mailing Address - Country:US
Mailing Address - Phone:410-226-0013
Mailing Address - Fax:410-226-0013
Practice Address - Street 1:112 FIRST ST.
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MD
Practice Address - Zip Code:21654-0532
Practice Address - Country:US
Practice Address - Phone:410-226-0013
Practice Address - Fax:410-226-0013
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0060132208000000X
NJMB-52712208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2290502Medicaid
NJ2290502Medicaid
129698Medicare ID - Type Unspecified