Provider Demographics
NPI:1043280548
Name:DIETZ, ANITA MARGOT (PT)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:MARGOT
Last Name:DIETZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SCHOFIELD RD
Mailing Address - Street 2:BLDG 1179
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-7577
Mailing Address - Country:US
Mailing Address - Phone:210-808-2226
Mailing Address - Fax:210-808-2225
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-808-2226
Practice Address - Fax:210-808-2225
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1094282225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX837T97OtherBLUE CROSS BLUE SHIELD
TX8L26943Medicare PIN