Healthcare Provider Details

I. General information

NPI: 1811920002
Provider Name (Legal Business Name): GARRY P. DIETER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 09/08/2021
Certification Date: 08/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UCLA DEPT ANESTHESIOLOGY AND PERIOP MEDICINE
LOS ANGELES CA
90095-3129
US

IV. Provider business mailing address

757 WESTWOOD PLZ STE 3304
LOS ANGELES CA
90095-9780
US

V. Phone/Fax

Practice location:
  • Phone: 310-267-8653
  • Fax:
Mailing address:
  • Phone: 310-267-0902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number9767
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number9767
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: