Provider Demographics
NPI:1174738397
Name:RICHARD E. DIETZEN, M.D.,P.A.
Entity type:Organization
Organization Name:RICHARD E. DIETZEN, M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DIETZEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-863-6444
Mailing Address - Street 1:403 W. OAK ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-4586
Mailing Address - Country:US
Mailing Address - Phone:870-863-6444
Mailing Address - Fax:870-863-6675
Practice Address - Street 1:403 W OAK ST
Practice Address - Street 2:SUITE 302
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4586
Practice Address - Country:US
Practice Address - Phone:870-863-6444
Practice Address - Fax:870-863-6675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-1069261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5K301Medicare ID - Type UnspecifiedPROVIDER NUMBER
ARA37657Medicare UPIN