Healthcare Provider Details

I. General information

NPI: 1518316140
Provider Name (Legal Business Name): JONATHAN EDWARDS DITTY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2016
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 PORTAGE AVE
SOUTH BEND IN
46628-9570
US

IV. Provider business mailing address

4440 PORTAGE AVE
SOUTH BEND IN
46628-9570
US

V. Phone/Fax

Practice location:
  • Phone: 574-204-6200
  • Fax: 574-239-1520
Mailing address:
  • Phone: 574-204-6200
  • Fax: 574-239-1520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01082081A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: