Provider Demographics
NPI:1669642351
Name:JOHN JAMES DITMARS, JR. DPM PC
Entity Type:Organization
Organization Name:JOHN JAMES DITMARS, JR. DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DITMARS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:405-262-6613
Mailing Address - Street 1:PO BOX 717
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-0717
Mailing Address - Country:US
Mailing Address - Phone:405-354-5191
Mailing Address - Fax:405-262-1088
Practice Address - Street 1:47 N KIMBELL RD
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-2251
Practice Address - Country:US
Practice Address - Phone:405-354-5191
Practice Address - Fax:405-262-1088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK142213EP1101X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200275890 AMedicaid
OK200275890 AMedicaid