Healthcare Provider Details

I. General information

NPI: 1760678163
Provider Name (Legal Business Name): ROBERT J DIEDERICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 LILLY RD NE
OLYMPIA WA
98506-5101
US

IV. Provider business mailing address

525 LILLY RD NE
OLYMPIA WA
98506-5101
US

V. Phone/Fax

Practice location:
  • Phone: 360-493-7230
  • Fax: 360-493-5524
Mailing address:
  • Phone: 360-493-7230
  • Fax: 360-493-5524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberML20008010
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: