Provider Demographics
NPI:1427059310
Name:DIECK, JOHN ANTHONY JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ANTHONY
Last Name:DIECK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1509
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78295-1509
Mailing Address - Country:US
Mailing Address - Phone:512-623-5300
Mailing Address - Fax:512-623-5399
Practice Address - Street 1:4316 JAMES CASEY ST
Practice Address - Street 2:BUILDING A
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1157
Practice Address - Country:US
Practice Address - Phone:512-623-5300
Practice Address - Fax:512-623-5399
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8081207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131632508Medicaid
TXP00706404OtherRAILROAD MEDICARE
TX060012108OtherMEDICARE RAILROAD
TX8BX076OtherBCBSTX
TX131632501Medicaid
TX131632507Medicaid
TXP00700180OtherMEDICARE RAILROAD
TX131632501Medicaid
TX8F20673Medicare PIN
TX8F8479Medicare PIN
TXP00700180OtherMEDICARE RAILROAD