Provider Demographics
NPI:1033136650
Name:DITTLER, KIMBERLY RUSSO (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:RUSSO
Last Name:DITTLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:LYNN
Other - Last Name:RUSSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1153 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3446
Mailing Address - Country:US
Mailing Address - Phone:617-983-7700
Mailing Address - Fax:617-983-7724
Practice Address - Street 1:1153 CENTRE ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-3446
Practice Address - Country:US
Practice Address - Phone:617-983-7700
Practice Address - Fax:617-983-7724
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054658207P00000X
IL036-113760207P00000X
MA236721207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113760Medicaid
IL036113760Medicaid
ILK20206Medicare PIN