MEDICARE: WALTER DIETRICH GRACIA, 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	2086S0105X	Surgery of the Hand (Surgery) Physician
2	2086S0122X	Plastic and Reconstructive Surgery Physician

General Provider Information

NPI Number	:	1568643500
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALTER DIETRICH GRACIA, M.D., P.A.

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	:	RECEPTIONIST
Name	:	MRS. DARIELA SANTOS
Credential	:
Telephone Number	:	817-336-9450

Provider Enumeration Date	:	11/19/2007
Last Update Date	:	10/08/2010

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