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General NPI Number Information
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NPI Number | 1528550654
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Entity Type | Organization
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Legal Business Name | JOHN DEITRICK MD CONSULTING, LLC
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Dates
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Enumeration Date | 06/04/2018
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Last Update Date | 02/18/2021
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Provider Practice Location Address
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Address Line | 173 WADSWORTH DR
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23236-4500
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Country | US
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Telephone | 804-674-5957
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 8987
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City | RICHMOND
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State | VA
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Zip | 23225-0687
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Country | US
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Telephone | 804-241-5911
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JOHN C DEITRICK
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Credential | MD
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Telephone | 804-241-5911
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | 0101037598
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License Number State | VA
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