Provider Demographics
NPI:1669456331
Name:DITAS, JAVIER (PA)
Entity Type:Individual
Prefix:MR
First Name:JAVIER
Middle Name:
Last Name:DITAS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3965 SW 152ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-3351
Mailing Address - Country:US
Mailing Address - Phone:954-392-1216
Mailing Address - Fax:
Practice Address - Street 1:9301 NW 33RD ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-1202
Practice Address - Country:US
Practice Address - Phone:305-437-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9102520363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant