Basic Information
| Provider Information | |||||||||
| NPI: | 1083110928 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DITTMER | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | RAYMOND | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3567 FAWN LN | ||||||||
| Address2: | |||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527227100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633705317 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2900 W OKLAHOMA AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532154330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146493323 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2018 | ||||||||
| LastUpdateDate: | 03/31/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.