Provider Demographics
NPI:1780660019
Name:DITESHEIM, JEFFREY ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
Last Name:DITESHEIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9336 BLAKENEY CENTER DRIVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277
Mailing Address - Country:US
Mailing Address - Phone:704-542-8686
Mailing Address - Fax:704-542-8696
Practice Address - Street 1:9336 BLAKENEY CENTER DRIVE
Practice Address - Street 2:SUITE 130
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277
Practice Address - Country:US
Practice Address - Phone:704-542-8686
Practice Address - Fax:704-542-8696
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC95012222086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCG16740Medicare UPIN
NC2217077AMedicare ID - Type Unspecified