Individual
JACK FOSTER DITTY JR.
Active
Individual
JACK FOSTER DITTY JR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
20687
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000048343
ANTHEM PROVIDER #
KY
05
—
024 1170
—
OH
01
—
20687
MEDICAL LICENSE
KY
01
—
611053554
TAX ID
KY
05
—
64206873
—
KY
Enumeration date
02/22/2007
Last updated
03/07/2023
Update your record
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