Individual
DR. WALTER DIETRICH GRACIA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1204 5TH AVE, FORT WORTH, TX 76104-4303
(817) 336-9450
(817) 336-3306
Mailing address
1204 5TH AVE, FORT WORTH, TX 76104-4303
(817) 336-9450
(817) 336-3306
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
G5103
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
126310502
—
TX
01
—
240002368
RAILROAD MEDICARE
TX
01
—
4273318
AETNA
TX
01
—
F97N
BLUE CROSS BLUE SHIELD
TX
Enumeration date
03/01/2006
Last updated
08/04/2014
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