MEDICARE: DR. DARRELL R PIETSCH 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	207Q00000X	Family Medicine Physician	K7867	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	8L10057	OTHER	TX	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8BZ212	OTHER	TX	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780689992
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DARRELL R PIETSCH M.D.

Provider Business Mailing Address
First Line	:	6600 FISH POND RD STE 202A
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76710-2582
Country	:	US
Telephone Number	:	254-732-6789
Fax Number	:	254-732-6790

Provider Business Practice Location Address
First Line	:	6600 FISH POND RD STE 202A
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76710-2582
Country	:	US
Telephone Number	:	254-732-6789
Fax Number	:	254-732-6790

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

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	01/08/2010

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