1760637243 NPI number — DAVID G DILLARD, MD, LLC

Table of content: (NPI 1760637243)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760637243 NPI number — DAVID G DILLARD, MD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID G DILLARD, MD, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760637243
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1728
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATKINSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30677-0034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-310-0252
Provider Business Mailing Address Fax Number:
706-769-2750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
771 OLD NORCROSS RD
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30045-4317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-689-1100
Provider Business Practice Location Address Fax Number:
678-689-1104
Provider Enumeration Date:
11/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DILLARD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
678-689-1100

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  040364 , registered in the state of GU ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000681227M , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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