Basic Information
| Provider Information | |||||||||
| NPI: | 1508857103 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIETER | ||||||||
| FirstName: | M. | ||||||||
| MiddleName: | LYNDON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DIETER | ||||||||
| OtherFirstName: | MARK | ||||||||
| OtherMiddleName: | LYNDON | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 660 S COOLIDGE ST | ||||||||
| Address2: | |||||||||
| City: | MOSES LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988371872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097939715 | ||||||||
| FaxNumber: | 5097643244 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 E WHEELER RD | ||||||||
| Address2: | |||||||||
| City: | MOSES LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988371899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097655606 | ||||||||
| FaxNumber: | 5097643244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 02/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 125.054676 | IL | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 036.124143 | IL | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207P00000X | 1452 | AZ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207L00000X | MD60212924 | WA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 2015006 | 05 | WA | MEDICAID | 453051001 | 01 | AZ | GROUP HEALTH GRP # | OTHER | 860373636 | 01 | AZ | HUMANA GROUP # | OTHER | AW1436 | 01 | AZ | HEALTHNET GRP # | OTHER | 3981220 | 01 | AZ | EVERCARE GROUP # | OTHER | 358566 | 05 | AZ | MEDICAID |