Provider Demographics
NPI:1972916864
Name:DIETRICH, KARL ADAM OLSON (MD)
Entity type:Individual
Prefix:
First Name:KARL
Middle Name:ADAM OLSON
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 1:590 COURT ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431
Mailing Address - Country:US
Mailing Address - Phone:603-354-5400
Mailing Address - Fax:
Practice Address - Street 1:590 COURT ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431
Practice Address - Country:US
Practice Address - Phone:603-354-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP03188207Q00000X
WAMD60747854207Q00000X
NH21950207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIRES000Medicare UPIN