Provider Demographics
NPI:1871580704
Name:DIETZEN, RICHARD EDWARD (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:EDWARD
Last Name:DIETZEN
Suffix:
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 2116
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71731-2116
Mailing Address - Country:US
Mailing Address - Phone:870-863-6444
Mailing Address - Fax:870-863-6675
Practice Address - Street 1:403 W OAK ST
Practice Address - Street 2:SUITE 302
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4586
Practice Address - Country:US
Practice Address - Phone:870-863-6444
Practice Address - Fax:870-863-6675
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-1069174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR136119002Medicaid
AR130492001Medicaid
ARA37657Medicare UPIN
AR136119002Medicaid