Provider Demographics
NPI:1437226511
Name:DILLER, JOHN LEWIS (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:LEWIS
Last Name:DILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 S MERIDIAN
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371
Mailing Address - Country:US
Mailing Address - Phone:253-845-2629
Mailing Address - Fax:253-845-2433
Practice Address - Street 1:610 S MERIDIAN
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371
Practice Address - Country:US
Practice Address - Phone:253-845-2629
Practice Address - Fax:253-845-2433
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00013892207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADI1840OtherREGENCE
WA1217207Medicaid
WA140045140045OtherPREMERA BLUE CROSS
WADI1840OtherREGENCE
WA140045140045OtherPREMERA BLUE CROSS