Provider Demographics
NPI:1861504508
Name:DITTLER, MARTIN (CRNA)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:DITTLER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 WEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:VA
Mailing Address - Zip Code:24151-4888
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1613 OAKWOOD ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523-1213
Practice Address - Country:US
Practice Address - Phone:540-586-2441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001082217163W00000X
VA0024082217367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8955140Medicaid
VA8955158Medicaid
VA8955115Medicaid
VA8955107Medicaid
VA8955123Medicaid
VA8955115Medicaid
R32024Medicare UPIN
VA8955140Medicaid