Provider Demographics
NPI:1174709182
Name:DIETRICH KUSCH, ANGELA M (MD)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:M
Last Name:DIETRICH KUSCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:M
Other - Last Name:DIETRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-274-1201
Mailing Address - Fax:317-278-9905
Practice Address - Street 1:1701 N SENATE AVE
Practice Address - Street 2:DEPT OF PEDIATRICS
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5306
Practice Address - Country:US
Practice Address - Phone:317-962-8067
Practice Address - Fax:317-962-3796
Is Sole Proprietor?:No
Enumeration Date:2008-01-21
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01067796208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200981870Medicaid