Provider Demographics
NPI:1568661577
Name:KLINGHARDT, DIETRICH KONRAD (MD)
Entity Type:Individual
Prefix:
First Name:DIETRICH
Middle Name:KONRAD
Last Name:KLINGHARDT
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 1:11656 98TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-4216
Mailing Address - Country:US
Mailing Address - Phone:425-823-8818
Mailing Address - Fax:425-823-8817
Practice Address - Street 1:11656 98TH AVE NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-4216
Practice Address - Country:US
Practice Address - Phone:425-823-8818
Practice Address - Fax:425-823-8817
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022065208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice