Provider Demographics
NPI:1598734592
Name:DIERWECHTER, LEAZA M (MD)
Entity Type:Individual
Prefix:
First Name:LEAZA
Middle Name:M
Last Name:DIERWECHTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3124 S 19TH ST
Mailing Address - Street 2:STE C220
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2433
Mailing Address - Country:US
Mailing Address - Phone:253-301-5050
Mailing Address - Fax:
Practice Address - Street 1:3124 S 19TH ST
Practice Address - Street 2:STE C220
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2433
Practice Address - Country:US
Practice Address - Phone:253-301-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00040441208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAH60863Medicare UPIN