Provider Demographics
NPI:1104800911
Name:DITCHEN, IZABELA J (MD)
Entity type:Individual
Prefix:
First Name:IZABELA
Middle Name:J
Last Name:DITCHEN
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:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:2714 RIVERVIEW DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-6715
Practice Address - Country:US
Practice Address - Phone:920-430-4760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45158207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34321800Medicaid
WI45158OtherLICENSE
WI34321800Medicaid
WI073050027Medicare Oscar/Certification
WI002707305Medicare Oscar/Certification
WI45158OtherLICENSE
WIH77827Medicare UPIN
WI075100045Medicare Oscar/Certification