Basic Information
| Provider Information | |||||||||
| NPI: | 1407919020 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DITMARS | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
| Address2: | 2799 WEST GRAND BLVD. | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139167425 | ||||||||
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| Practice Location | |||||||||
| Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
| Address2: | 2799 WEST GRAND BLVD. | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139167425 | ||||||||
| FaxNumber: | 3138743623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 4301024493 | MI | Y | Allopathic & Osteopathic Physicians | Plastic Surgery | 208600000X | 4301024493 | MI | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | DD024493 | 01 | COMMERCIAL-COMMERCIAL NUMBER | OTHER | 121286710 | 05 | MI | MEDICAID | DD024493 | 01 | CHAMPUS-CHAMPUS | OTHER | 700H262310 | 01 | BLUE CROSS-BLUE CROSS | OTHER |