Basic Information
| Provider Information | |||||||||
| NPI: | 1134434889 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DITZ | ||||||||
| FirstName: | JERRY | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12909 | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285612909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526369800 | ||||||||
| FaxNumber: | 2526361945 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 BRANCHWOOD SHOPPING CTR | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285465800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109387555 | ||||||||
| FaxNumber: | 9109387544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2010 | ||||||||
| LastUpdateDate: | 08/18/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12715 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.