Provider Demographics
NPI:1134147978
Name:KITTREDGE, BEN W (MD)
Entity type:Individual
Prefix:
First Name:BEN
Middle Name:W
Last Name:KITTREDGE
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:PO BOX 75868
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-5868
Mailing Address - Country:US
Mailing Address - Phone:703-383-6469
Mailing Address - Fax:
Practice Address - Street 1:6355 WALKER LANE
Practice Address - Street 2:SUITE 202
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-3257
Practice Address - Country:US
Practice Address - Phone:703-810-5210
Practice Address - Fax:703-810-5418
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055642207X00000X
MDD51741207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDM77089OtherCONTROLLED SUBSTANCE LICENSE
VA6408028Medicaid
MDD51741OtherMARYLAND MEDICAL LICENSE
MDD51741OtherMARYLAND MEDICAL LICENSE
MDFK3672436OtherMARYLAND DEA LICENSE
0962280008Medicare NSC
MDD51741OtherMARYLAND MEDICAL LICENSE
0962280008Medicare NSC