Provider Demographics
NPI:1164645156
Name:DIESEL, DOUGLAS LEE (CPO, LPO)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LEE
Last Name:DIESEL
Suffix:
Gender:M
Credentials:CPO, LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 W HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75092-7409
Mailing Address - Country:US
Mailing Address - Phone:903-891-0230
Mailing Address - Fax:903-891-8743
Practice Address - Street 1:1411 W HOUSTON ST
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-7409
Practice Address - Country:US
Practice Address - Phone:903-891-0230
Practice Address - Fax:903-891-8743
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX255222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX531778OtherBCBS
TX5380770001Medicare NSC