Healthcare Provider Details

I. General information

NPI: 1669642351
Provider Name (Legal Business Name): JOHN JAMES DITMARS, JR. DPM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 03/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 N KIMBELL RD
YUKON OK
73099-2251
US

IV. Provider business mailing address

PO BOX 717
EL RENO OK
73036-0717
US

V. Phone/Fax

Practice location:
  • Phone: 405-354-5191
  • Fax: 405-262-1088
Mailing address:
  • Phone: 405-354-5191
  • Fax: 405-262-1088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number142
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number142
License Number StateOK

VIII. Authorized Official

Name: DR. JOHN JAMES DITMARS JR.
Title or Position: PRESIDENT
Credential: DPM
Phone: 405-262-6613