Provider Demographics
NPI:1811901887
Name:DIETLEIN, JON FREDRICK (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:FREDRICK
Last Name:DIETLEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0298207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC15258Medicare UPIN
TX8F1721Medicare ID - Type Unspecified