Healthcare Provider Details

I. General information

NPI: 1518911536
Provider Name (Legal Business Name): BOB DENNIS DIETRICH D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13400 E SHEA BLVD MAYO CLINIC ARIZONA
SCOTTSDALE AZ
85259-5404
US

IV. Provider business mailing address

13400 E SHEA BLVD
SCOTTSDALE AZ
85259-5452
US

V. Phone/Fax

Practice location:
  • Phone: 480-301-8000
  • Fax:
Mailing address:
  • Phone: 480-301-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number3365
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: