Healthcare Provider Details

I. General information

NPI: 1770744104
Provider Name (Legal Business Name): JOHN A DIECK PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316 JAMES CASEY ST BLDG. A
AUSTIN TX
78745-1157
US

IV. Provider business mailing address

PO BOX 13045
AUSTIN TX
78711-3045
US

V. Phone/Fax

Practice location:
  • Phone: 512-623-5300
  • Fax: 512-623-5399
Mailing address:
  • Phone: 512-623-5300
  • Fax: 512-623-5399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG8081
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberG8081
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberG8081
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberG8081
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG8081
License Number StateTX

VIII. Authorized Official

Name: JOHN A DIECK JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 512-623-5300