Provider Demographics
NPI:1942430178
Name:DITTMAN, JOE CABALHIN (IDMT)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:CABALHIN
Last Name:DITTMAN
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8019 BRADT CT
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME A F B
Mailing Address - State:ID
Mailing Address - Zip Code:83648-1064
Mailing Address - Country:US
Mailing Address - Phone:208-832-1067
Mailing Address - Fax:
Practice Address - Street 1:90 HOPE DR BLDG 6000
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME A F B
Practice Address - State:ID
Practice Address - Zip Code:83648-1062
Practice Address - Country:US
Practice Address - Phone:208-828-7313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians