MEDICARE: KATIE M DITOMMASO

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	225100000X	Physical Therapist	5221	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	EIN	OTHER	OK	OTHER

General Provider Information

NPI Number	:	1821559832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATIE M DITOMMASO

Provider Business Mailing Address
First Line	:	2016 N LEE AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73103-1816
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2016 N LEE AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73103-1816
Country	:	US
Telephone Number	:	859-640-2436
Fax Number	:

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

Provider Enumeration Date	:	03/31/2019
Last Update Date	:	03/31/2019

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Directions to “ KATIE M DITOMMASO ” Practice Location

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