Healthcare Provider Details

I. General information

NPI: 1194899682
Provider Name (Legal Business Name): MICHAEL RICHARD DITTRICH NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 COYLE AVE
CARMICHAEL CA
95608-0302
US

IV. Provider business mailing address

2646 STOUGHTON WAY
SACRAMENTO CA
95827-1069
US

V. Phone/Fax

Practice location:
  • Phone: 916-536-3540
  • Fax:
Mailing address:
  • Phone: 916-733-3333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberNP6056
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: