Provider Demographics
NPI:1518920412
Name:DIETERLE, BRIAN D (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:DIETERLE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:670 BRANSON LANDING BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-2063
Mailing Address - Country:US
Mailing Address - Phone:417-334-0810
Mailing Address - Fax:417-334-6685
Practice Address - Street 1:670 BRANSON LANDING BLVD STE 2
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-2063
Practice Address - Country:US
Practice Address - Phone:417-334-0810
Practice Address - Fax:417-334-6685
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2023-10-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO102259207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO008345586Medicare PIN