Provider Demographics
NPI:1326395112
Name:DITZLER, MATTHEW GERALD (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GERALD
Last Name:DITZLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 WELBORN ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-3924
Mailing Address - Country:US
Mailing Address - Phone:214-559-7549
Mailing Address - Fax:
Practice Address - Street 1:2222 WELBORN ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-3924
Practice Address - Country:US
Practice Address - Phone:214-559-7549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR36622085R0202X, 2085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology