Provider Demographics
NPI:1942487137
Name:BRIAN D DIETERLE MD PC
Entity Type:Organization
Organization Name:BRIAN D DIETERLE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:DIETERLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-334-0810
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102259207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203602404Medicaid
MO203602404Medicaid