Active NPI
Dallas Diederich, PA-C
- Physician Assistant
- Flint, TX
National Provider Identifier
1982729216
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- PA00509
- Practice address
- 20208 State Highway 155 S
Flint, TX 75762-5600 - Phone
- (903) 825-6222
- NPI assigned
- Mar 19, 2007
- Last updated
- Aug 7, 2015
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | PA00509 | TX | Primary |
Addresses
Primary practice location
20208 State Highway 155 S
Flint, TX 75762-5600
Mailing address
PO Box 846098
Dallas, TX 75284-6098
Phone (903) 324-6400
Other identifiers 19
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 752616977002 | Other | TX | TRICARE |
| 8N3412 | Other | TX | BCBS |
| 202460601 | Medicaid | TX | |
| 75-0818167-022 | Other | TX | TRICARE |
| 752616977001 | Other | TX | TRICARE |
| 202460604 | Medicaid | TX | |
| 75-1976930-005 | Other | TX | TRICARE |
| 8689NN | Other | TX | BCBS |
| 202460602 | Medicaid | TX | |
| 752616977028 | Other | TX | TRICARE |
| 8EW436 | Other | TX | BCBS |
| 8679NN | Other | TX | BCBS |
| 202460603 | Medicaid | TX | |
| 75-0818167-044 | Other | TX | TRICARE |
| 75-0818167-048 | Other | TX | TRICARE |
| 75-2616977-001 | Other | TRICARE | |
| P01478957 | Other | TX | RAIL ROAD MEDICARE |
| 75-0818167-015 | Other | TX | TRICARE |
| P01478958 | Other | TX | RAIL ROAD MEDICARE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1174262400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1438905600000",
"number": "1982729216",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 846098",
"city": "DALLAS",
"state": "TX",
"postal_code": "752846098",
"telephone_number": "903-324-6400"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "20208 STATE HIGHWAY 155 S",
"city": "FLINT",
"state": "TX",
"postal_code": "757625600",
"telephone_number": "903-825-6222"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DIEDERICH",
"first_name": "DALLAS",
"credential": "PA-C",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-03-19",
"last_updated": "2015-08-07",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "TX",
"license": "PA00509",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TRICARE",
"identifier": "752616977002",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS",
"identifier": "8N3412",
"state": "TX"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "202460601",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TRICARE",
"identifier": "75-0818167-022",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TRICARE",
"identifier": "752616977001",
"state": "TX"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "202460604",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TRICARE",
"identifier": "75-1976930-005",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS",
"identifier": "8689NN",
"state": "TX"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "202460602",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TRICARE",
"identifier": "752616977028",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS",
"identifier": "8EW436",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS",
"identifier": "8679NN",
"state": "TX"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "202460603",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TRICARE",
"identifier": "75-0818167-044",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TRICARE",
"identifier": "75-0818167-048",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TRICARE",
"identifier": "75-2616977-001",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RAIL ROAD MEDICARE",
"identifier": "P01478957",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TRICARE",
"identifier": "75-0818167-015",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RAIL ROAD MEDICARE",
"identifier": "P01478958",
"state": "TX"
}
],
"endpoints": [],
"other_names": []
}Other providers in Flint, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 7, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.