Provider Demographics
NPI:1043325400
Name:DILLARD, GARY AMON (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:AMON
Last Name:DILLARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 STADIUM DRIVE STE 240
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867
Mailing Address - Country:US
Mailing Address - Phone:334-291-8303
Mailing Address - Fax:334-291-8325
Practice Address - Street 1:1810 STADIUM DRIVE STE 240
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867
Practice Address - Country:US
Practice Address - Phone:334-291-8303
Practice Address - Fax:334-291-8325
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9197207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009907905Medicaid
C72171Medicare UPIN
AL051512167DILMedicare ID - Type Unspecified
GA08BBXHPMedicare ID - Type Unspecified