Provider Demographics
NPI:1982924767
Name:JOHN L. DILLER, MD
Entity Type:Organization
Organization Name:JOHN L. DILLER, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:DILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-845-2629
Mailing Address - Street 1:610 S MERIDIAN
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-5908
Mailing Address - Country:US
Mailing Address - Phone:253-845-2629
Mailing Address - Fax:253-845-2433
Practice Address - Street 1:610 S MERIDIAN
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-5908
Practice Address - Country:US
Practice Address - Phone:253-845-2629
Practice Address - Fax:253-845-2433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00013892261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1217207Medicaid