1053654608 NPI number — DR. TIMOTHY JOHN DIETRICH D.O

Table of content: DR. TIMOTHY JOHN DIETRICH D.O (NPI 1053654608)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053654608 NPI number — DR. TIMOTHY JOHN DIETRICH D.O

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIETRICH
Provider First Name:
TIMOTHY
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053654608
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 CLUB MANOR DRIVE
Provider Second Line Business Mailing Address:
, SUITE 2
Provider Business Mailing Address City Name:
MAUMELLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72113-7401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-851-7402
Provider Business Mailing Address Fax Number:
501-851-4753

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1705 CLUB MANOR DRIVE,
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
MAUMELLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72113-7401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-851-7402
Provider Business Practice Location Address Fax Number:
501-851-4753
Provider Enumeration Date:
04/02/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  E-3259 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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