Basic Information
| Provider Information | |||||||||
| NPI: | 1093920506 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN DITRAGLIA INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 717 5TH ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456624007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403546605 | ||||||||
| FaxNumber: | 7403541565 | ||||||||
| Practice Location | |||||||||
| Address1: | 717 5TH ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456624007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403546605 | ||||||||
| FaxNumber: | 7403541565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 03/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | DITRAGLIA | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | FRANCIS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7403546605 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 35047660 | OH | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261QP2300X | 35047660 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 64781438 | 05 | KY | MEDICAID |