Provider Demographics
NPI:1780689992
Name:PIETSCH, DARRELL R (MD)
Entity Type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:R
Last Name:PIETSCH
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 1:6600 FISH POND RD STE 202A
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-2582
Mailing Address - Country:US
Mailing Address - Phone:254-732-6789
Mailing Address - Fax:254-732-6790
Practice Address - Street 1:6600 FISH POND RD STE 202A
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-2582
Practice Address - Country:US
Practice Address - Phone:254-732-6789
Practice Address - Fax:254-732-6790
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BZ212OtherBCBS
TX103631105Medicaid
TX8L10057OtherMEDICARE
TX103631103Medicaid
TX8BZ212OtherBCBS
TX103631103Medicaid