Provider Demographics
NPI:1245207141
Name:GRACIA, WALTER DIETRICH (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:DIETRICH
Last Name:GRACIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4303
Mailing Address - Country:US
Mailing Address - Phone:817-336-9450
Mailing Address - Fax:817-336-3306
Practice Address - Street 1:1204 5TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4303
Practice Address - Country:US
Practice Address - Phone:817-336-9450
Practice Address - Fax:817-336-3306
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5103174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF97NOtherBLUE CROSS BLUE SHIELD
TX126310502Medicaid
TX240002368OtherRAILROAD MEDICARE
TX4273318OtherAETNA
TX240002368OtherRAILROAD MEDICARE
TX4273318OtherAETNA