MEDICARE: DR. JONATHAN S. DEITCH M.D.

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	2086S0129X	Vascular Surgery Physician	194966-1	NY
2	2086S0129X	Vascular Surgery Physician	T3610	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679551469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN S. DEITCH M.D.

Provider Business Mailing Address
First Line	:	1325 PENNSYLVANIA AVE STE 680
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2133
Country	:	US
Telephone Number	:	817-250-4235
Fax Number	:

Provider Business Practice Location Address
First Line	:	1325 PENNSYLVANIA AVE STE 680
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2133
Country	:	US
Telephone Number	:	817-250-4235
Fax Number	:

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

Provider Enumeration Date	:	01/03/2006
Last Update Date	:	10/20/2021

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Directions to “ DR. JONATHAN S. DEITCH M.D.” Practice Location

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