Provider Demographics
NPI:1033240049
Name:HILLIARD, DEIDRE K (MD)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:K
Last Name:HILLIARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 SOUTHERN AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-4623
Mailing Address - Country:US
Mailing Address - Phone:202-741-2302
Mailing Address - Fax:202-741-2637
Practice Address - Street 1:1310 SOUTHERN AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-4623
Practice Address - Country:US
Practice Address - Phone:202-741-2302
Practice Address - Fax:202-741-2637
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207R0000X207R00000X
DCMD043436208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50026299OtherPASSPORT HEALTH PLAN
KY000000640112OtherBC/BS
KY7100089620Medicaid
KYP00829877OtherRAILROAD MEDICARE
KY3746248000OtherPASSPORT ADVANTAGE
KY3746248000OtherPASSPORT ADVANTAGE