1972981215 NPI number — DR. CALLISTUS N. DITAH MD

Table of content: DR. CALLISTUS N. DITAH MD (NPI 1972981215)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972981215 NPI number — DR. CALLISTUS N. DITAH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DITAH
Provider First Name:
CALLISTUS
Provider Middle Name:
N.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1972981215
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
739 IRVING AVE
Provider Second Line Business Mailing Address:
SUITE 640
Provider Business Mailing Address City Name:
SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13210-5095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-464-6255
Provider Business Mailing Address Fax Number:
615-464-6251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
739 IRVING AVE
Provider Second Line Business Practice Location Address:
SUITE 640
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13210-5095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-464-6255
Provider Business Practice Location Address Fax Number:
615-464-6251
Provider Enumeration Date:
05/07/2015

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: 208G00000X , with the licence number:  330140 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208G00000X , with the licence number: MD61423828 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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