Individual
DALLAS DIEDERICH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
20208 STATE HIGHWAY 155 S, FLINT, TX 75762-5600
(903) 825-6222
Mailing address
PO BOX 846098, DALLAS, TX 75284-6098
(903) 324-6400
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA00509
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
202460601
—
TX
05
—
202460602
—
TX
05
—
202460603
—
TX
05
—
202460604
—
TX
01
—
75-0818167-015
TRICARE
TX
01
—
75-0818167-022
TRICARE
TX
01
—
75-0818167-044
TRICARE
TX
01
—
75-0818167-048
TRICARE
TX
01
—
75-1976930-005
TRICARE
TX
01
—
75-2616977-001
TRICARE
—
01
—
752616977001
TRICARE
TX
01
—
752616977002
TRICARE
TX
01
—
752616977028
TRICARE
TX
01
—
8679NN
BCBS
TX
01
—
8689NN
BCBS
TX
01
—
8EW436
BCBS
TX
01
—
8N3412
BCBS
TX
01
—
P01478957
RAIL ROAD MEDICARE
TX
01
—
P01478958
RAIL ROAD MEDICARE
TX
Enumeration date
03/19/2007
Last updated
08/07/2015
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