Provider Demographics
NPI:1194077420
Name:DIEKER, KALEB A (OD)
Entity type:Individual
Prefix:DR
First Name:KALEB
Middle Name:A
Last Name:DIEKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 S 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3961
Mailing Address - Country:US
Mailing Address - Phone:509-966-2966
Mailing Address - Fax:509-966-3230
Practice Address - Street 1:1211 S 40TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3961
Practice Address - Country:US
Practice Address - Phone:509-966-2966
Practice Address - Fax:509-966-3230
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60610901152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2059167Medicaid
WAG8953385Medicare Oscar/Certification