MEDICARE: DR. WALTER DIETRICH GRACIA 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	174400000X	Specialist	G5103	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	240002368	OTHER	TX	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	F97N	OTHER	TX	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	4273318	OTHER	TX	AETNA

General Provider Information

NPI Number	:	1245207141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WALTER DIETRICH GRACIA M.D.

Provider Business Mailing Address
First Line	:	1204 5TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4303
Country	:	US
Telephone Number	:	817-336-9450
Fax Number	:	817-336-3306

Provider Business Practice Location Address
First Line	:	1204 5TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4303
Country	:	US
Telephone Number	:	817-336-9450
Fax Number	:	817-336-3306

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

Provider Enumeration Date	:	03/01/2006
Last Update Date	:	08/04/2014

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