Provider Demographics
NPI:1962455535
Name:DIETSCH, FERNANDO JR (MD)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:DIETSCH
Suffix:JR
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 1:21 W IMPERIAL ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4457
Mailing Address - Country:US
Mailing Address - Phone:509-301-9342
Mailing Address - Fax:509-786-6612
Practice Address - Street 1:723 MEMORIAL ST
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-1524
Practice Address - Country:US
Practice Address - Phone:509-786-2222
Practice Address - Fax:509-786-6612
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041643207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA162391OtherLABOR & INDUSTRIES #
WA8325656Medicaid
WAAB33328Medicare ID - Type UnspecifiedMEDICARE PHYSICIAN #
WA8325656Medicaid
WA162391OtherLABOR & INDUSTRIES #
WA8857668Medicare ID - Type UnspecifiedMEDICARE PART B