1477550093 NPI number — DANIEL DILLARD MD

Table of content: DANIEL DILLARD MD (NPI 1477550093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477550093 NPI number — DANIEL DILLARD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DILLARD
Provider First Name:
DANIEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1477550093
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4202 S UNIVERSITY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72204-7841
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-562-4838
Provider Business Mailing Address Fax Number:
501-562-1958

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4202 S UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72204-7841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-562-4838
Provider Business Practice Location Address Fax Number:
501-562-1958
Provider Enumeration Date:
06/29/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  C4472 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 120025 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 11114000000 . This is a "QUALCHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 51379 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 104404001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".