Provider Demographics
NPI:1669642500
Name:DITTMAR, CALLYN ROSE (DC)
Entity Type:Individual
Prefix:DR
First Name:CALLYN
Middle Name:ROSE
Last Name:DITTMAR
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BRADY ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-5214
Mailing Address - Country:US
Mailing Address - Phone:563-884-5801
Mailing Address - Fax:563-884-5470
Practice Address - Street 1:1000 BRADY ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-5214
Practice Address - Country:US
Practice Address - Phone:563-884-5801
Practice Address - Fax:563-884-5470
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011137111N00000X
IA007111111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK51752Medicare PIN