Healthcare Provider Details

I. General information

NPI: 1194721506
Provider Name (Legal Business Name): SCOTT A DIETRICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1137 W PENN AVE
WOMELSDORF PA
19567-9770
US

IV. Provider business mailing address

PO BOX 13579
READING PA
19612-3579
US

V. Phone/Fax

Practice location:
  • Phone: 610-589-2555
  • Fax: 610-589-4940
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD045097L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: