Basic Information
| Provider Information | |||||||||
| NPI: | 1902897895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DITTRICH | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2002 MEDICAL PKWY | ||||||||
| Address2: | SUITE #235 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102662770 | ||||||||
| FaxNumber: | 4108416251 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 MEDICAL PKWY | ||||||||
| Address2: | SUITE #235 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102662770 | ||||||||
| FaxNumber: | 4108416251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 11/13/2007 | ||||||||
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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 | 2085R0204X | D0058803 | MD | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | E488 | 01 | MD | AAD AA COUNTY | OTHER | 10690026 | 01 | MD | BCBS | OTHER | 545L E502 | 01 | MD | AAD SHIPLEYS | OTHER | 8317071 | 01 | MD | AETNA PPO | OTHER | 300134259 | 01 | MD | RR MEDICARE | OTHER | 434340900 | 05 | MD | MEDICAID | 2622593 | 01 | MD | AETNA HMO/POS | OTHER | G01780A06 | 01 | MD | AAD PG COUNTY | OTHER |