Provider Demographics
NPI:1801057179
Name:DIETRICH, LINDSEY NICOLE (MD)
Entity type:Individual
Prefix:
First Name:LINDSEY
Middle Name:NICOLE
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 PARK SPRINGS BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-1935
Mailing Address - Country:US
Mailing Address - Phone:817-960-9120
Mailing Address - Fax:
Practice Address - Street 1:4401 PARK SPRINGS BLVD STE 130
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-1935
Practice Address - Country:US
Practice Address - Phone:817-960-9120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXQ0243207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX337287201Medicaid
TX354500YKPWMedicare PIN