1669642351 NPI number — JOHN JAMES DITMARS, JR. DPM PC

Table of content: (NPI 1669642351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669642351 NPI number — JOHN JAMES DITMARS, JR. DPM PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN JAMES DITMARS, JR. DPM PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669642351
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 717
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL RENO
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73036-0717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-354-5191
Provider Business Mailing Address Fax Number:
405-262-1088

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
47 N KIMBELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YUKON
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73099-2251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-354-5191
Provider Business Practice Location Address Fax Number:
405-262-1088
Provider Enumeration Date:
03/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DITMARS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
405-262-6613

Provider Taxonomy Codes

  • Taxonomy code: 213EP1101X , with the licence number:  142 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 142 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200275890 A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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