Provider Demographics
NPI:1982761482
Name:DITTENBER, BRIAN A (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:A
Last Name:DITTENBER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 W CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:SUNBURY
Mailing Address - State:OH
Mailing Address - Zip Code:43074-8556
Mailing Address - Country:US
Mailing Address - Phone:740-965-4671
Mailing Address - Fax:
Practice Address - Street 1:690 W CHERRY ST
Practice Address - Street 2:
Practice Address - City:SUNBURY
Practice Address - State:OH
Practice Address - Zip Code:43074-8556
Practice Address - Country:US
Practice Address - Phone:740-965-4671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3226152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0400793Medicaid
OHDI0491291Medicare ID - Type Unspecified