Provider Demographics
NPI:1922181676
Name:DITMANSON, PAUL M (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:M
Last Name:DITMANSON
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:HWY 1 BOX 497
Mailing Address - Street 2:PHS INDIAN HOSPITAL
Mailing Address - City:RED LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671
Mailing Address - Country:US
Mailing Address - Phone:218-679-3912
Mailing Address - Fax:218-679-0181
Practice Address - Street 1:HWY 1 BOX 497
Practice Address - Street 2:PHS INDIAN HOSPITAL
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671
Practice Address - Country:US
Practice Address - Phone:218-679-3912
Practice Address - Fax:218-679-0181
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30915207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN476753500Medicaid
MN30915OtherMINNESOTA LICENSE
MN30915OtherMINNESOTA LICENSE
MN8HZ59QMedicare PIN
MNG2691Medicare UPIN