Provider Demographics
NPI:1902088438
Name:DITTMAR, KRISTIN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:DITTMAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8900 WILSHIRE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1967
Mailing Address - Country:US
Mailing Address - Phone:310-432-8947
Mailing Address - Fax:310-432-8968
Practice Address - Street 1:8900 WILSHIRE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1966
Practice Address - Country:US
Practice Address - Phone:310-432-8947
Practice Address - Fax:310-432-8968
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA910012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A910010Medicaid
CAWA91001AMedicare PIN
CA00A910010Medicaid