Provider Demographics
NPI:1548336803
Name:DIETRICH, RICHARD LAROY (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LAROY
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICAIRE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:4920 CAMPBELL BLVD
Practice Address - Street 2:KAISER PERMANENTE WHITE MARSH MEDICAL CENTER
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-5916
Practice Address - Country:US
Practice Address - Phone:410-933-7600
Practice Address - Fax:410-933-7802
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2011-11-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0026218208000000X
VA0101221514208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D78065Medicare UPIN
546789M92Medicare ID - Type Unspecified