Individual
JACK FOSTER DITTY JR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
100 SAINT CHRISTOPHER DR, ASHLAND, KY 41101-7016
(606) 836-3111
(606) 833-5660
Mailing address
100 SAINT CHRISTOPHER DR, ASHLAND, KY 41101-7016
(606) 836-3111
(606) 833-5660
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
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