=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669642351
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN JAMES DITMARS, JR. DPM PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2008
-----------------------------------------------------
Last Update Date | 03/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 47 N KIMBELL RD
-----------------------------------------------------
City | YUKON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73099-2251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-354-5191
-----------------------------------------------------
Fax | 405-262-1088
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 717
-----------------------------------------------------
City | EL RENO
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73036-0717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-354-5191
-----------------------------------------------------
Fax | 405-262-1088
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN JAMES DITMARS JR.
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 405-262-6613
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213EP1101X
-----------------------------------------------------
Taxonomy Name | Primary Podiatric Medicine Podiatrist
-----------------------------------------------------
License Number | 142
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 142
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------