Provider Demographics
NPI:1003103490
Name:DILLINGHAM, JUSTIN JAMES (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:JAMES
Last Name:DILLINGHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3126 S JACKSON AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-2534
Mailing Address - Country:US
Mailing Address - Phone:417-208-3465
Mailing Address - Fax:
Practice Address - Street 1:3126 S JACKSON AVE
Practice Address - Street 2:STE 101
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-2534
Practice Address - Country:US
Practice Address - Phone:417-208-3465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014010517207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1003103490Medicaid
MOMA2082380Medicare PIN