Provider Demographics
NPI:1619188216
Name:DIETRICH, KATHERINE LYNNE METZGER (DO)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:LYNNE METZGER
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1000 AUAHI ST APT 1603
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-3358
Mailing Address - Country:US
Mailing Address - Phone:406-606-2168
Mailing Address - Fax:084-330-2818
Practice Address - Street 1:459 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-1522
Practice Address - Country:US
Practice Address - Phone:808-583-3167
Practice Address - Fax:808-433-0281
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ005587207R00000X
MT40873207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1619188216Medicaid
AZ637117Medicaid
MT1619188216Medicaid