Provider Demographics
NPI:1093146003
Name:DIETER, MICHELLE (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DIETER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2965 W 3500 S
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-3602
Mailing Address - Country:US
Mailing Address - Phone:801-965-3600
Mailing Address - Fax:
Practice Address - Street 1:2965 W 3500 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-3602
Practice Address - Country:US
Practice Address - Phone:801-965-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-02
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11929878-1204207P00000X
CA20A13278207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine