Provider Demographics
NPI:1740315589
Name:DITTY, JACK FOSTER JR (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:FOSTER
Last Name:DITTY
Suffix:JR
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 1:100 SAINT CHRISTOPHER DR
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-7016
Mailing Address - Country:US
Mailing Address - Phone:606-836-3111
Mailing Address - Fax:606-833-5660
Practice Address - Street 1:100 SAINT CHRISTOPHER DR
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7016
Practice Address - Country:US
Practice Address - Phone:606-836-3111
Practice Address - Fax:606-833-5660
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20687207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY611053554OtherTAX ID
KY64206873Medicaid
OH024 1170Medicaid
KY000000048343OtherANTHEM PROVIDER #
KY20687OtherMEDICAL LICENSE
KY20687OtherMEDICAL LICENSE
KY611053554OtherTAX ID
KYAD9266823OtherDEA #
C74177Medicare UPIN