Basic Information
| Provider Information | |||||||||
| NPI: | 1265440101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DITMARS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3903 LONE TREE WAY | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945096249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257570800 | ||||||||
| FaxNumber: | 9257572160 | ||||||||
| Practice Location | |||||||||
| Address1: | 3903 LONE TREE WAY | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945096249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257570800 | ||||||||
| FaxNumber: | 9257572160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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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 | 208600000X | G080207 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.