Provider Demographics
NPI:1609396530
Name:DIETRICH, JOSEPH D (DC)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:D
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:DC
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 700688
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78270-0688
Mailing Address - Country:US
Mailing Address - Phone:210-318-3007
Mailing Address - Fax:210-468-0682
Practice Address - Street 1:14008 SHADOWGLEN BLVD STE 104
Practice Address - Street 2:
Practice Address - City:MANOR
Practice Address - State:TX
Practice Address - Zip Code:78653-3406
Practice Address - Country:US
Practice Address - Phone:800-404-6050
Practice Address - Fax:866-313-3397
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14068111NR0400X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCHR.0008376OtherCHIROPRACTIC LICENSE
TX14068OtherCHIROPRACTIC LICENSE