Provider Demographics
NPI:1811920002
Name:DIETER, GARRY P (MD)
Entity type:Individual
Prefix:
First Name:GARRY
Middle Name:P
Last Name:DIETER
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 1:757 WESTWOOD PLZ STE 3304
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-9780
Mailing Address - Country:US
Mailing Address - Phone:310-267-0902
Mailing Address - Fax:
Practice Address - Street 1:UCLA DEPT ANESTHESIOLOGY AND PERIOP MEDICINE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3129
Practice Address - Country:US
Practice Address - Phone:310-267-8653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9767207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0043771Medicaid
WA8409377Medicaid
ID806528000Medicaid
MT0080240Medicaid
MT0080240Medicaid
H41382Medicare UPIN
MT0043771Medicaid