Provider Demographics
NPI:1063675692
Name:DITAH, FAUSTA
Entity Type:Individual
Prefix:DR
First Name:FAUSTA
Middle Name:
Last Name:DITAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 ARCHIBALD DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-2212
Mailing Address - Country:US
Mailing Address - Phone:734-709-8776
Mailing Address - Fax:931-502-3815
Practice Address - Street 1:647 DUNLOP LN STE 210
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5165
Practice Address - Country:US
Practice Address - Phone:931-502-3810
Practice Address - Fax:931-502-3815
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2022-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD50497207RG0100X
MI4301092128207PE0004X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services