Provider Demographics
NPI:1447452081
Name:MICHAEL J. DITOMASSO PH.D., P.A.
Entity type:Organization
Organization Name:MICHAEL J. DITOMASSO PH.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:DITOMASSO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:305-256-5610
Mailing Address - Street 1:13834 SW 122ND CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-6052
Mailing Address - Country:US
Mailing Address - Phone:305-256-4324
Mailing Address - Fax:305-256-5610
Practice Address - Street 1:13834 SW 122ND CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-6052
Practice Address - Country:US
Practice Address - Phone:305-256-4324
Practice Address - Fax:305-256-5610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 5449103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7672951Medicaid
FL59897OtherBLUE CROSS PROVIDER NUMBE