1093844094 NPI number — MS. ELIZABETH A DITTMAR RD CDN

Table of content: MS. ELIZABETH A DITTMAR RD CDN (NPI 1093844094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093844094 NPI number — MS. ELIZABETH A DITTMAR RD CDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DITTMAR
Provider First Name:
ELIZABETH
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RD CDN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARTIN
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093844094
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 505
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JORDAN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13080-0505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-689-3774
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 S WILBUR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13204-2732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-253-6283
Provider Business Practice Location Address Fax Number:
315-282-0024
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  003379-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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