Provider Demographics
NPI:1902897895
Name:DITTRICH, JASON R (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:R
Last Name:DITTRICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 MEDICAL PKWY
Mailing Address - Street 2:SUITE #235
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3046
Mailing Address - Country:US
Mailing Address - Phone:410-266-2770
Mailing Address - Fax:410-841-6251
Practice Address - Street 1:2002 MEDICAL PKWY
Practice Address - Street 2:SUITE #235
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3046
Practice Address - Country:US
Practice Address - Phone:410-266-2770
Practice Address - Fax:410-841-6251
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00588032085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE488OtherAAD AA COUNTY
MD10690026OtherBCBS
MD545L E502OtherAAD SHIPLEYS
MD8317071OtherAETNA PPO
MD300134259OtherRR MEDICARE
MD434340900Medicaid
MD2622593OtherAETNA HMO/POS
MDG01780A06OtherAAD PG COUNTY
MD2622593OtherAETNA HMO/POS
MDS629D963Medicare ID - Type Unspecified
MD300134259OtherRR MEDICARE
MD545L E502OtherAAD SHIPLEYS
MD434340900Medicaid
MDG93846Medicare UPIN