Basic Information
| Provider Information | |||||||||
| NPI: | 1033174362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIETRICH | ||||||||
| FirstName: | AARON | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 BRADHURST AVE STE 3100N | ||||||||
| Address2: | |||||||||
| City: | HAWTHORNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105322140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149099018 | ||||||||
| FaxNumber: | 9149099028 | ||||||||
| Practice Location | |||||||||
| Address1: | 27 GRAND ST | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124013933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453381535 | ||||||||
| FaxNumber: | 8453349879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 06/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 208411-1 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01951399 | 05 | NY | MEDICAID |