MEDICARE: MR. JOHN BRETT DIETZE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207T00000X	Neurological Surgery Physician	K2152	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1G1885	OTHER	TX	MEDICARE
9	140006859	OTHER	TX	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	141100101	OTHER		INDIGENT HEALTH CARE
3	18796000000	OTHER	AR	QUALCHOICE OF ARKANSAS
4	98601	OTHER	TX	COLLUM & CARNEY CLINIC
5	98601	OTHER	AR	BLUE CROSS
6	179117500	OTHER		US DEPT OF LABOR
7	1871793307	OTHER	TX	CIGNA DME
8	8A0896	OTHER	TX	BLUE CROSS
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
12	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
13	5575000001	OTHER	TX	CIGNA GOVERNMENT SERVICES
14	MDK2152	OTHER	TX	WORKERS' COMPENSATION
15	98601	OTHER		FIRST PYRAMID LIFE

General Provider Information

NPI Number	:	1588665319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN BRETT DIETZE MD

Provider Business Mailing Address
First Line	:	P O BOX 9600
Second Line	:	DEPT 09-019
City	:	TEXARKANA
State	:	TX
Zip	:	75505-9600
Country	:	US
Telephone Number	:	903-794-4196
Fax Number	:	903-792-7408

Provider Business Practice Location Address
First Line	:	2602 SAINT MICHAEL DR STE 302B
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-5228
Country	:	US
Telephone Number	:	903-794-4196
Fax Number	:	903-614-5169

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	04/28/2021

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