Provider Demographics
NPI:1629168356
Name:DITMAR, MARK F (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:F
Last Name:DITMAR
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:NEMOURS CHILDRENS CLINIC
Mailing Address - Street 2:P.O. BOX 404112
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0001
Mailing Address - Country:US
Mailing Address - Phone:904-390-3610
Mailing Address - Fax:904-288-5890
Practice Address - Street 1:ATLANTICARE REGIONAL MEDICAL CENTER
Practice Address - Street 2:JIMMIE LEEDS ROAD
Practice Address - City:POMONA
Practice Address - State:NJ
Practice Address - Zip Code:08240-9104
Practice Address - Country:US
Practice Address - Phone:609-652-1000
Practice Address - Fax:609-748-5988
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA05362200208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0152005Medicaid
MD5127068Medicaid
PA001053760Medicaid
B41364Medicare UPIN
NJ0152005Medicaid