Provider Demographics
NPI:1679549018
Name:DIETRICH, SHENEN LEAVITT (DO)
Entity type:Individual
Prefix:
First Name:SHENEN
Middle Name:LEAVITT
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SHENEN
Other - Middle Name:
Other - Last Name:LEAVITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:9377 E BELL RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-1502
Mailing Address - Country:US
Mailing Address - Phone:480-619-4097
Mailing Address - Fax:480-619-4098
Practice Address - Street 1:9377 E BELL RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1502
Practice Address - Country:US
Practice Address - Phone:480-261-9409
Practice Address - Fax:480-619-4098
Is Sole Proprietor?:No
Enumeration Date:2006-02-26
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3379207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ52849005Medicaid
AZP00046563OtherRAIL ROAD MEDICARE ID
AZ582490Medicaid
AZ582490Medicaid
AZP00046563OtherRAIL ROAD MEDICARE ID
AZZ75029Medicare PIN