Provider Demographics
NPI:1245374115
Name:DIETER, MICHAEL V (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:V
Last Name:DIETER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12000 ELM CREEK BLVD N STE L90
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7168
Mailing Address - Country:US
Mailing Address - Phone:763-416-0919
Mailing Address - Fax:763-416-0992
Practice Address - Street 1:12000 ELM CREEK BLVD N STE L90
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7168
Practice Address - Country:US
Practice Address - Phone:763-416-0919
Practice Address - Fax:763-416-0992
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1693152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1396DIOtherBLUE CROSS BLUE SHIELD
MN844323800Medicaid
MN1396DIOtherBLUE CROSS BLUE SHIELD
MNT65458Medicare UPIN