Provider Demographics
NPI:1336148766
Name:DIESTELHORST, JAMES BRAD (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:BRAD
Last Name:DIESTELHORST
Suffix:
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:PO BOX 5096
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-5096
Mailing Address - Country:US
Mailing Address - Phone:360-738-2200
Mailing Address - Fax:360-752-5687
Practice Address - Street 1:4545 CORDATA PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-7123
Practice Address - Country:US
Practice Address - Phone:360-738-2200
Practice Address - Fax:360-752-5687
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041071207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4912DIOtherREGENCE
WA7704353OtherAETNA
WA1336148766Medicaid
WA0230369OtherL&I/CRIME VICTIMS
AKMD4918WOtherALASKA MEDICAID
WA0230369OtherL&I AND CRIME VICTIMS
AKMD4918WOtherALASKA MEDICAID
WAH61573Medicare UPIN