Provider Demographics
NPI:1437194552
Name:DITTRICH, MARY O'KIEF (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:O'KIEF
Last Name:DITTRICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 HOLDEN LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-5060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3525 E LOUISE DR
Practice Address - Street 2:STE 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6302
Practice Address - Country:US
Practice Address - Phone:208-846-8335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7706207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDI03187Medicare UPIN