Provider Demographics
NPI:1285797621
Name:JON F DIETLEIN MD PA
Entity type:Organization
Organization Name:JON F DIETLEIN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:F
Authorized Official - Last Name:DIETLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-931-2255
Mailing Address - Street 1:311 RIVER BEND DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-2782
Mailing Address - Country:US
Mailing Address - Phone:512-931-2255
Mailing Address - Fax:512-819-9528
Practice Address - Street 1:311 RIVER BEND DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-2782
Practice Address - Country:US
Practice Address - Phone:512-931-2255
Practice Address - Fax:512-819-9528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX04076T152W00000X
TXH0298207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT04076Medicare UPIN
TXC15258Medicare UPIN
TX8F1721Medicare ID - Type UnspecifiedDR. JON DIETLEIN NUMBER
TX8F1722Medicare ID - Type UnspecifiedDR. PAMELA EVAN-BERG #
TX00806ZMedicare ID - Type UnspecifiedGROUP