Provider Demographics
NPI:1295860930
Name:JON F DIETLEIN, M.D., P.A.
Entity Type:Organization
Organization Name:JON F DIETLEIN, M.D., P.A.
Other - Org Name:DIETLEIN OPTICAL BOUTIQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:F
Authorized Official - Last Name:DIETLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-931-2255
Mailing Address - Street 1:311 RIVER BEND DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-2782
Mailing Address - Country:US
Mailing Address - Phone:512-931-2255
Mailing Address - Fax:512-819-9528
Practice Address - Street 1:311 RIVER BEND DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-2782
Practice Address - Country:US
Practice Address - Phone:512-931-2255
Practice Address - Fax:512-819-9528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT04076Medicare UPIN
TX4862310001Medicare NSC
TXC1528Medicare UPIN