Individual
GARY D DIEDERICH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
859 LAKE ST, BRISTOL, NH 03222-4506
(603) 744-6200
(603) 744-9024
Mailing address
101 BOULDER POINT DR, SUITE 1, PLYMOUTH, NH 03264
(603) 536-4000
(603) 536-4001
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
6515
NH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
80000321
—
NH
01
—
RE4060
MEDICARE GROUP
NH
Enumeration date
06/08/2006
Last updated
11/30/2007
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