Provider Demographics
NPI:1710188438
Name:DITTER, SUSAN MARIE (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:DITTER
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 ENBORG LN
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2608
Mailing Address - Country:US
Mailing Address - Phone:408-885-6220
Mailing Address - Fax:408-885-3977
Practice Address - Street 1:2221 ENBORG LN
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2608
Practice Address - Country:US
Practice Address - Phone:408-885-6220
Practice Address - Fax:408-885-3977
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG878432084P0800X
VA01012366752084P0800X, 2084F0202X
GA0248032084P0800X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA006594U92Medicare ID - Type Unspecified
GAD29310Medicare UPIN