Provider Demographics
NPI:1982714010
Name:BAUTISTA-DITTMAR, MIDA N (PT)
Entity type:Individual
Prefix:
First Name:MIDA
Middle Name:N
Last Name:BAUTISTA-DITTMAR
Suffix:
Gender:F
Credentials:PT
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 764
Mailing Address - Street 2:
Mailing Address - City:CHANNAHON
Mailing Address - State:IL
Mailing Address - Zip Code:60410-0764
Mailing Address - Country:US
Mailing Address - Phone:815-223-4479
Mailing Address - Fax:815-223-4479
Practice Address - Street 1:1627 4TH ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-3507
Practice Address - Country:US
Practice Address - Phone:815-223-4479
Practice Address - Fax:815-223-4489
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70007736225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK16156Medicare PIN