Provider Demographics
NPI:1417938713
Name:DIETZE, THOMAS RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:RUSSELL
Last Name:DIETZE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5402 S STAPLES ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-4656
Mailing Address - Country:US
Mailing Address - Phone:361-992-9400
Mailing Address - Fax:361-992-8295
Practice Address - Street 1:5402 S STAPLES ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4656
Practice Address - Country:US
Practice Address - Phone:361-992-9400
Practice Address - Fax:361-992-8295
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2019-02-28
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Provider Licenses
StateLicense IDTaxonomies
TXH1574207WX0120X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX129833303Medicaid
TXB22271Medicare UPIN