=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386999787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACK F. DITTY, MD, PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2012
-----------------------------------------------------
Last Update Date | 07/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 SAINT CHRISTOPHER DR
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41101-7016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-836-3111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 SAINT CHRISTOPHER DR
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41101-7016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-836-3111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | JACK DITTY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 606-836-3111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------