Provider Demographics
NPI:1982889507
Name:JOHN A DIETRICK M D P L
Entity type:Organization
Organization Name:JOHN A DIETRICK M D P L
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIETRICK
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:813-971-8883
Mailing Address - Street 1:13801 BRUCE B DOWNS BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-3946
Mailing Address - Country:US
Mailing Address - Phone:813-971-8883
Mailing Address - Fax:813-971-2491
Practice Address - Street 1:13801 BRUCE B DOWNS BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-3946
Practice Address - Country:US
Practice Address - Phone:813-971-8883
Practice Address - Fax:813-971-2491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88224208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8167Medicare PIN