MEDICARE: RICHARD E. DIETZEN, M.D.,P.A.

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	261QM2500X	Medical Specialty Clinic/Center	E-1069	AR

General Provider Information

NPI Number	:	1174738397
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RICHARD E. DIETZEN, M.D.,P.A.

Provider Business Mailing Address
First Line	:	403 W. OAK ST
Second Line	:	SUITE 302
City	:	EL DORADO
State	:	AR
Zip	:	71730-4586
Country	:	US
Telephone Number	:	870-863-6444
Fax Number	:	870-863-6675

Provider Business Practice Location Address
First Line	:	403 W OAK ST
Second Line	:	SUITE 302
City	:	EL DORADO
State	:	AR
Zip	:	71730-4586
Country	:	US
Telephone Number	:	870-863-6444
Fax Number	:	870-863-6675

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. RICHARD EDWARD DIETZEN
Credential	:	M.D.
Telephone Number	:	870-863-6444

Provider Enumeration Date	:	05/11/2007
Last Update Date	:	01/18/2008

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