Provider Demographics
NPI:1093015000
Name:DILLARD, DERECK L
Entity Type:Individual
Prefix:MR
First Name:DERECK
Middle Name:L
Last Name:DILLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07106-1944
Mailing Address - Country:US
Mailing Address - Phone:646-355-5583
Mailing Address - Fax:
Practice Address - Street 1:870 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07106-1944
Practice Address - Country:US
Practice Address - Phone:646-355-5583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-25
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide