Provider Demographics
NPI:1265502629
Name:DILL, DIANE (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:DILL
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:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-0130
Mailing Address - Country:US
Mailing Address - Phone:970-858-2186
Mailing Address - Fax:970-858-2208
Practice Address - Street 1:281 N PLUM ST
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-2100
Practice Address - Country:US
Practice Address - Phone:970-858-9894
Practice Address - Fax:970-858-1331
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31586207Q00000X
CODR.0031586208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1315860Medicaid
CO1315860Medicaid
CODID3281OtherBLUE CROSS
CODID3281OtherBLUE CROSS
COP00189822OtherRR MEDICARE