Healthcare Provider Details

I. General information

NPI: 1710981741
Provider Name (Legal Business Name): ANTHONY PAUL DIETRICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 05/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 BERRY CREEK DR
FLAT ROCK NC
28731-8531
US

IV. Provider business mailing address

114 BERRY CREEK DR
FLAT ROCK NC
28731-8531
US

V. Phone/Fax

Practice location:
  • Phone: 828-697-0333
  • Fax: 828-697-0375
Mailing address:
  • Phone: 828-697-0333
  • Fax: 828-697-0375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2009-00644
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number042-0008490
License Number StateVT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: