Provider Demographics
NPI:1679895502
Name:DITTMEYER, BRENT EUGENE
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:EUGENE
Last Name:DITTMEYER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 W OWEN GARRIOTT ROAD
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703
Mailing Address - Country:US
Mailing Address - Phone:580-234-8021
Mailing Address - Fax:580-233-9363
Practice Address - Street 1:4010 W OWEN K GARRIOTT RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-4803
Practice Address - Country:US
Practice Address - Phone:580-234-8021
Practice Address - Fax:580-233-9363
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9617183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100235410FMedicaid