Provider Demographics
NPI:1770664682
Name:DEITCHMAN, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:DEITCHMAN
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 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:731 MARTIN RD
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-2703
Practice Address - Country:US
Practice Address - Phone:817-514-0346
Practice Address - Fax:817-514-0885
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3709208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX433103OtherPHCS PIN
TX5105745OtherAETNA PIN
TX86W438OtherBCBSTX IND PIN
TX1640375OtherFIRSTHEALTH PIN
TX1761903OtherUHC PIN
TX7293476OtherCIGNA PIN
TX045262503OtherCSHCN
1750369203OtherGRP NPI NUMBER
TX00U87ZOtherBCBSTX GRP PIN
TX045262502Medicaid
TXDEIMG53535OtherCCHIP PIN
TXDEIMG53535OtherCCHIP PIN
TX045262503OtherCSHCN