Healthcare Provider Details

I. General information

NPI: 1619963444
Provider Name (Legal Business Name): TODD B DIETRICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date: 03/24/2006
Reactivation Date: 04/06/2006

III. Provider practice location address

800 S RAYMOND AVE
PASADENA CA
91105-3229
US

IV. Provider business mailing address

PO BOX 90730
PASADENA CA
91109-0730
US

V. Phone/Fax

Practice location:
  • Phone: 626-795-8051
  • Fax: 626-795-0356
Mailing address:
  • Phone: 626-795-8051
  • Fax: 626-795-0356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA70565
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberA70565
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: