Provider Demographics
NPI:1053341669
Name:DIETRICH, DANIEL SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:SCOTT
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:546 E PINE ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5525
Mailing Address - Country:US
Mailing Address - Phone:209-467-1000
Mailing Address - Fax:
Practice Address - Street 1:546 E PINE ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5525
Practice Address - Country:US
Practice Address - Phone:209-467-1000
Practice Address - Fax:209-464-4439
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA957312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology