Provider Demographics
NPI:1508857103
Name:DIETER, M. LYNDON (MD)
Entity Type:Individual
Prefix:DR
First Name:M.
Middle Name:LYNDON
Last Name:DIETER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:LYNDON
Other - Last Name:DIETER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:660 S COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1872
Mailing Address - Country:US
Mailing Address - Phone:509-793-9715
Mailing Address - Fax:509-764-3244
Practice Address - Street 1:801 E WHEELER RD
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1899
Practice Address - Country:US
Practice Address - Phone:509-765-5606
Practice Address - Fax:509-764-3244
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.054676207L00000X
IL036.124143207L00000X
AZ1452207P00000X
WAMD60212924207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2015006Medicaid
AZ453051001OtherGROUP HEALTH GRP #
AZ860373636OtherHUMANA GROUP #
AZAW1436OtherHEALTHNET GRP #
AZ3981220OtherEVERCARE GROUP #
AZ358566Medicaid
S15813Medicare UPIN