Basic Information
| Provider Information | |||||||||
| NPI: | 1326395112 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DITZLER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | GERALD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | GALVESTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775550709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097472849 | ||||||||
| FaxNumber: | 4097727120 | ||||||||
| Practice Location | |||||||||
| Address1: | 6701 FANNIN ST STE 470 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8328247237 | ||||||||
| FaxNumber: | 8328250160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2012 | ||||||||
| LastUpdateDate: | 02/26/2019 | ||||||||
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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 | 2085P0229X | R3662 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | R3662 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.