Provider Demographics
NPI:1235192188
Name:DILLMAN, DIANA L (DO)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:DILLMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:7686 GEORGETOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8101
Practice Address - Country:US
Practice Address - Phone:616-252-8600
Practice Address - Fax:616-252-8660
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013865207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1235192188Medicaid
MIH52178Medicare UPIN
MIM53750066Medicare PIN
MI08-5-70-1060-4OtherBCBS PIN