Provider Demographics
NPI:1962145714
Name:DITMORE, MICHAEL ANTHONY
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:DITMORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164484 5 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MARLOW
Mailing Address - State:OK
Mailing Address - Zip Code:73055-5282
Mailing Address - Country:US
Mailing Address - Phone:580-721-1221
Mailing Address - Fax:
Practice Address - Street 1:1016 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-4761
Practice Address - Country:US
Practice Address - Phone:580-606-6719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator