Basic Information
| Provider Information | |||||||||
| NPI: | 1093146003 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIETER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6041 CADILLAC AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900341702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238572000 | ||||||||
| FaxNumber: | 9732907202 | ||||||||
| Practice Location | |||||||||
| Address1: | 6041 CADILLAC AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900341702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238572000 | ||||||||
| FaxNumber: | 9732907202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2013 | ||||||||
| LastUpdateDate: | 11/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 20A13278 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.