Provider Demographics
NPI:1033140983
Name:DITMARS, JOHN JAMES JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JAMES
Last Name:DITMARS
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 610
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-0610
Mailing Address - Country:US
Mailing Address - Phone:405-262-6613
Mailing Address - Fax:405-262-1088
Practice Address - Street 1:1620 W ELM ST
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-4202
Practice Address - Country:US
Practice Address - Phone:405-262-6613
Practice Address - Fax:405-262-1088
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK142213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100780220AMedicaid
OK73-1490445-003OtherBLUE CROSS & BLUE SHIELD
OK480019883OtherRR MEDICARE
OK73-1490445-003OtherBLUE CROSS & BLUE SHIELD