Provider Demographics
NPI:1184640658
Name:JONATHAN F. DILLER, M.D., INC.
Entity Type:Organization
Organization Name:JONATHAN F. DILLER, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:FORD
Authorized Official - Last Name:DILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-332-9978
Mailing Address - Street 1:2575 HAYES AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-5201
Mailing Address - Country:US
Mailing Address - Phone:419-332-9978
Mailing Address - Fax:419-332-7989
Practice Address - Street 1:2575 HAYES AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-5201
Practice Address - Country:US
Practice Address - Phone:419-332-9978
Practice Address - Fax:419-332-7989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-045285207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2811407Medicaid
OH35-045285OtherOH MEDICAL LICENSE
OHA83678Medicare UPIN
OH2811407Medicaid
OHDH1279Medicare PIN