Provider Demographics
NPI:1508894692
Name:DITZENBERGER, MARK R (DC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:DITZENBERGER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 N. 7 HIGHWAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014-2436
Mailing Address - Country:US
Mailing Address - Phone:816-224-6200
Mailing Address - Fax:816-224-2788
Practice Address - Street 1:701 N. 7 HIGHWAY
Practice Address - Street 2:SUITE B
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2436
Practice Address - Country:US
Practice Address - Phone:816-224-6200
Practice Address - Fax:816-224-2788
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38010718111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08220357OtherBCBS OF IL