Individual
TERRY J DIETRICH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1405 MILL ST, NEW LONDON, WI 54961-2155
(920) 831-5050
Mailing address
PO BOX 8003, APPLETON, WI 54912-8003
(920) 996-3298
(920) 738-5787
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
49333-020
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
450030720
MEDICARE PTAN
WI
Enumeration date
06/15/2006
Last updated
11/23/2011
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