Provider Demographics
NPI:1588610596
Name:DIETEL, DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:DIETEL
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:PO BOX 4078
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4078
Mailing Address - Country:US
Mailing Address - Phone:888-633-0086
Mailing Address - Fax:
Practice Address - Street 1:1255 HILYARD ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3718
Practice Address - Country:US
Practice Address - Phone:503-686-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17206207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E11195OtherGROUP HEALTH
CAXPY185040Medicaid
WA8280026Medicaid
E11195OtherLIPA
OR029574Medicaid
J0475-03OtherPACIFIC SOURCE
76162OtherWA L & I
E11195OtherPROVIDENCE
76162OtherWA L & I
CAXPY185040Medicaid
CD2802Medicare PIN
E11195Medicare UPIN
0000WFBBXMedicare PIN