Provider Demographics
NPI:1316387061
Name:DITTO, SHEY KYLE (DO)
Entity Type:Individual
Prefix:
First Name:SHEY
Middle Name:KYLE
Last Name:DITTO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11615 ANGUS RD STE 106
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-4064
Mailing Address - Country:US
Mailing Address - Phone:512-436-9986
Mailing Address - Fax:512-436-8295
Practice Address - Street 1:11615 ANGUS RD STE 106
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4064
Practice Address - Country:US
Practice Address - Phone:512-436-9986
Practice Address - Fax:512-436-8295
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ7861208600000X, 202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX393647801Medicaid
TXQ7861OtherMEDICAL LICENSE
TXF06001452OtherDEA