Provider Demographics
NPI:1649560038
Name:DIETIKER, KRISTIN LYNN (MD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LYNN
Last Name:DIETIKER
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:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-820-2000
Mailing Address - Fax:
Practice Address - Street 1:303 N. KEENE ST.
Practice Address - Street 2:SUITE 404
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201
Practice Address - Country:US
Practice Address - Phone:573-777-7627
Practice Address - Fax:573-777-4596
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014008188208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
MOPENDINGMedicaid