Healthcare Provider Details

I. General information

NPI: 1528150984
Provider Name (Legal Business Name): DIANE CAMPBELL RITTER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 12/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 BOATNER RD
EGLIN AFB FL
32542-1302
US

IV. Provider business mailing address

307 BOATNER RD
EGLIN AFB FL
32542-1302
US

V. Phone/Fax

Practice location:
  • Phone: 210-859-0007
  • Fax:
Mailing address:
  • Phone: 210-859-0007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number14967
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number14967
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License NumberMD.14967
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number14967
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: