Provider Demographics
NPI:1942249727
Name:DITTENBIR, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:DITTENBIR
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 1:601 JOHN ST
Mailing Address - Street 2:SUITE M283A
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-349-7696
Mailing Address - Fax:269-488-8313
Practice Address - Street 1:601 JOHN ST STE M283A
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-349-7696
Practice Address - Fax:269-488-8313
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010486922086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI020C91020OtherBCBS GRP PIN
MI3403901640OtherBCBS IND PIN
5515041OtherAETNA PIN
116658OtherGREAT LAKES HLTH PLN
MI1417961137OtherBCBSM - BRONSON
MI1942249727Medicaid
MI3218986-10Medicaid
MI3403901640OtherBCBS IND PIN
MI3403901640OtherBCBS IND PIN
5515041OtherAETNA PIN
MIC97618289 BMHMedicare PIN
MICC2425Medicare PIN
MICC2425Medicare PIN