Provider Demographics
NPI:1578982831
Name:DIETZ, STEPHEN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ROBERT
Last Name:DIETZ
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:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-456-0488
Mailing Address - Fax:214-456-4486
Practice Address - Street 1:5323 HARRY HINES BOULEVARD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7201
Practice Address - Country:US
Practice Address - Phone:214-456-0488
Practice Address - Fax:214-456-4486
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXR4537208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program