MEDICARE: MARIANNE DIETRICH DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	180858	NY

General Provider Information

NPI Number	:	1992880017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIANNE DIETRICH DO

Provider Business Mailing Address
First Line	:	3380 RESERVOIR OVAL
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10467-3101
Country	:	US
Telephone Number	:	718-696-4060
Fax Number	:	718-231-1586

Provider Business Practice Location Address
First Line	:	3380 RESERVOIR OVAL
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10467-3101
Country	:	US
Telephone Number	:	718-696-4060
Fax Number	:	718-231-1586

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	07/08/2010

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