Healthcare Provider Details

I. General information

NPI: 1720183650
Provider Name (Legal Business Name): FREDERICK WILLIAM DIETERICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 11/13/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 VALLE TERRACE
VISTA CA
92064
US

IV. Provider business mailing address

16671 YORBA LINDA BLVD STE 200
YORBA LINDA CA
92886-2025
US

V. Phone/Fax

Practice location:
  • Phone: 760-631-5000
  • Fax: 760-414-3892
Mailing address:
  • Phone: 714-996-3700
  • Fax: 714-993-5897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberGO41537
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberG041537
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: