Healthcare Provider Details

I. General information

NPI: 1467475202
Provider Name (Legal Business Name): JOSEPH ANTHONY DIETERLE JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 FIRST ST.
OXFORD MD
21654-0532
US

IV. Provider business mailing address

BOX 532 112 FIRST ST.
OXFORD MD
21654-0532
US

V. Phone/Fax

Practice location:
  • Phone: 410-226-0013
  • Fax: 410-226-0013
Mailing address:
  • Phone: 410-226-0013
  • Fax: 410-226-0013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberH0060132
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: