Provider Demographics
NPI:1568643500
Name:WALTER DIETRICH GRACIA, M.D., P.A.
Entity type:Organization
Organization Name:WALTER DIETRICH GRACIA, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:DARIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-336-9450
Mailing Address - Street 1:1204 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4303
Mailing Address - Country:US
Mailing Address - Phone:817-336-9450
Mailing Address - Fax:817-336-3306
Practice Address - Street 1:1204 5TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4303
Practice Address - Country:US
Practice Address - Phone:817-336-9450
Practice Address - Fax:817-336-3306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the HandGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00911ZMedicare PIN