Provider Demographics
NPI:1205987419
Name:DIETER, JONATHAN L JR (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:L
Last Name:DIETER
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 1:8014 MYRTLE TRACE DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8945
Mailing Address - Country:US
Mailing Address - Phone:843-347-7224
Mailing Address - Fax:843-347-7335
Practice Address - Street 1:8014 MYRTLE TRACE DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8945
Practice Address - Country:US
Practice Address - Phone:843-347-7224
Practice Address - Fax:843-347-7335
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7055207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC4269Medicaid
SC2958Medicare ID - Type Unspecified
SCPC4269Medicaid