Provider Demographics
NPI:1588665319
Name:DIETZE, JOHN BRETT (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:BRETT
Last Name:DIETZE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:P O BOX 9600
Mailing Address - Street 2:DEPT 09-019
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505-9600
Mailing Address - Country:US
Mailing Address - Phone:903-794-4196
Mailing Address - Fax:903-792-7408
Practice Address - Street 1:2602 SAINT MICHAEL DR STE 302B
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-5228
Practice Address - Country:US
Practice Address - Phone:903-794-4196
Practice Address - Fax:903-614-5169
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2021-04-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXK2152207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1G1885OtherMEDICARE
141100101OtherINDIGENT HEALTH CARE
AR18796000000OtherQUALCHOICE OF ARKANSAS
TX98601OtherCOLLUM & CARNEY CLINIC
AR98601OtherBLUE CROSS
179117500OtherUS DEPT OF LABOR
TX1871793307OtherCIGNA DME
TX8A0896OtherBLUE CROSS
TX140006859OtherRAILROAD MEDICARE
TX141100101Medicaid
AR142238001Medicaid
OK200023040AMedicaid
TX5575000001OtherCIGNA GOVERNMENT SERVICES
TXMDK2152OtherWORKERS' COMPENSATION
98601OtherFIRST PYRAMID LIFE
TX141100101Medicaid