Provider Demographics
NPI:1003814013
Name:DITTRICH, KAREN ANNE (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:ANNE
Last Name:DITTRICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5444 S. GREEN ST.
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5632
Mailing Address - Country:US
Mailing Address - Phone:801-262-8120
Mailing Address - Fax:801-262-3897
Practice Address - Street 1:5444 S. GREEN ST.
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84123-5632
Practice Address - Country:US
Practice Address - Phone:801-262-8120
Practice Address - Fax:801-262-3897
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT185077-12052085R0202X
IDM-114692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1003814013OtherREGENCE BCBSUT
UT107005898106OtherSELECTHEALTH
UT311802OtherDESERET MUTUAL BENEFITS ADMINISTRATORS
UTP00616149OtherRAILROAD MEDICARE
UTD0076Medicaid
UTP00041680OtherRAILROAD MEDICARE
WY120442400Medicaid
ID807039500Medicaid
UT107005898103OtherSELECTHEALTH
UT1003814013OtherUUHP
UT103721OtherPEHP
UTP00183606Medicare PIN
UT107005898103OtherSELECTHEALTH
UT103721OtherPEHP
UTP00041680OtherRAILROAD MEDICARE
UT005784901Medicare PIN