Provider Demographics
NPI:1760478143
Name:DITZLER, JOHN W JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:DITZLER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1901 VETERANS MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504-7451
Mailing Address - Country:US
Mailing Address - Phone:254-743-2174
Mailing Address - Fax:254-743-2346
Practice Address - Street 1:1901 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-7451
Practice Address - Country:US
Practice Address - Phone:254-743-2174
Practice Address - Fax:254-743-2346
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXE3175207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102601502Medicaid
B22318Medicare UPIN
TX102601502Medicaid