Provider Demographics
NPI:1093844094
Name:DITTMAR, ELIZABETH A (RD CDN)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:A
Last Name:DITTMAR
Suffix:
Gender:F
Credentials:RD CDN
Other - Prefix:MR
Other - First Name:ELIZABETH
Other - Middle Name:D
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 505
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:NY
Mailing Address - Zip Code:13080-0505
Mailing Address - Country:US
Mailing Address - Phone:315-689-3774
Mailing Address - Fax:
Practice Address - Street 1:800 S WILBUR AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-2732
Practice Address - Country:US
Practice Address - Phone:315-253-6283
Practice Address - Fax:315-282-0024
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003379-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered