Provider Demographics
NPI:1316905862
Name:DITTRICH, LEE B (MD)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:B
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 1:123 FOX RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3369
Mailing Address - Country:US
Mailing Address - Phone:865-690-9467
Mailing Address - Fax:
Practice Address - Street 1:123 FOX RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3369
Practice Address - Country:US
Practice Address - Phone:865-690-9467
Practice Address - Fax:865-637-5057
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36383207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7120405OtherAETNA
TN3874778OtherBLUE CROSS
TNQ007919Medicaid
TNH70922Medicare UPIN
TN3376258Medicaid