Provider Demographics
NPI:1346972353
Name:DILLARD, DESHUNTA
Entity Type:Individual
Prefix:
First Name:DESHUNTA
Middle Name:
Last Name:DILLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 FAIRY STREET EXT STE B
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-1913
Mailing Address - Country:US
Mailing Address - Phone:276-201-1647
Mailing Address - Fax:
Practice Address - Street 1:314 FAIRY STREET EXT STE B
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1913
Practice Address - Country:US
Practice Address - Phone:276-201-1647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA84-34824252083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine