Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 142 | OK |
Y | 222Z00000X | Podiatrist | 142 | OK |
NPI | 1033140983 |
---|---|
Provider Name | Dr. John James Ditmars JR. |
First Address | El Reno, OK 73036-0610 |
Second Address | El Reno, OK 73036-4202 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2006 |
Last Update Date | 06/06/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100780220A | (05) | OK |
480019883 | RR MEDICARE (01) | OK |
73-1490445-003 | BLUE CROSS & BLUE SHIELD (01) | OK |
T79929 | (02) | OK |