Provider Demographics
NPI:1811933864
Name:DITSLEAR, JOHN H (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:DITSLEAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7250 CLEARVISTA DRIVE
Practice Address - Street 2:SUITE 230
Practice Address - City:INDPLS
Practice Address - State:IN
Practice Address - Zip Code:46256-4640
Practice Address - Country:US
Practice Address - Phone:317-621-7771
Practice Address - Fax:317-621-6040
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045848A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00169887OtherRR MEDICARE CLARIAN
IN200219370Medicaid
IN020043808OtherRR MEDICARE TS
IN000000821044OtherANTHEM
INP01275421OtherMEDICARE RR PTAN
IN247010FMedicare PIN
G96814Medicare UPIN
IN000000821044OtherANTHEM
IN200219370Medicaid
INP01163193Medicare PIN
IN200219370Medicaid