Provider Demographics
NPI:1639597636
Name:DIETRICH, KEVIN CLAYTON (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:CLAYTON
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2746 OLD US 20 WEST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ELKART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1365
Mailing Address - Country:US
Mailing Address - Phone:574-293-3545
Mailing Address - Fax:574-522-0599
Practice Address - Street 1:2746 OLD US 20 WEST
Practice Address - Street 2:SUITE B
Practice Address - City:ELKART
Practice Address - State:IN
Practice Address - Zip Code:46514-1365
Practice Address - Country:US
Practice Address - Phone:574-293-3545
Practice Address - Fax:574-522-0599
Is Sole Proprietor?:No
Enumeration Date:2014-04-07
Last Update Date:2025-08-14
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Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01095440A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program