MEDICARE: DR. JONATHAN EDWARDS DITTY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01082081A	IN
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1518316140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN EDWARDS DITTY M.D.

Provider Business Mailing Address
First Line	:	4440 PORTAGE AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628-9570
Country	:	US
Telephone Number	:	574-204-6200
Fax Number	:	574-239-1520

Provider Business Practice Location Address
First Line	:	4440 PORTAGE AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628-9570
Country	:	US
Telephone Number	:	574-204-6200
Fax Number	:	574-239-1520

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2016
Last Update Date	:	06/28/2019

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