Provider Demographics
NPI:1407919020
Name:DITMARS, DONALD M (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:M
Last Name:DITMARS
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:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:2799 WEST GRAND BLVD.
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-916-7425
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:2799 WEST GRAND BLVD.
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-916-7425
Practice Address - Fax:313-874-3623
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301024493208200000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DD024493OtherCOMMERCIAL-COMMERCIAL NUMBER
MI121286710Medicaid
DD024493OtherCHAMPUS-CHAMPUS
700H262310OtherBLUE CROSS-BLUE CROSS