Provider Demographics
NPI:1497750707
Name:DITTO, ALLEN WILSON (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:WILSON
Last Name:DITTO
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:P O BOX 412047
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241
Mailing Address - Country:US
Mailing Address - Phone:301-790-9044
Mailing Address - Fax:301-790-9096
Practice Address - Street 1:13620 CRAYTON BOULEVARD
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742
Practice Address - Country:US
Practice Address - Phone:240-313-9890
Practice Address - Fax:240-313-9890
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD26806207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD256671100Medicaid
MDB67232Medicare UPIN
MD256671100Medicaid
MDKQ29LJ60Medicare ID - Type Unspecified