Provider Demographics
NPI:1124101225
Name:DITCH, CARL M (MD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:M
Last Name:DITCH
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 1:2316 E. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560
Mailing Address - Country:US
Mailing Address - Phone:337-364-1103
Mailing Address - Fax:337-364-1194
Practice Address - Street 1:2316 E. MAIN ST.
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560
Practice Address - Country:US
Practice Address - Phone:337-364-1103
Practice Address - Fax:337-364-1194
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013926207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1199150Medicaid
LAB62340Medicare UPIN
LA1199150Medicaid
B62340Medicare UPIN