Provider Demographics
NPI:1376778654
Name:DILLER, ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:DILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 SALEM ST
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45309-8227
Mailing Address - Country:US
Mailing Address - Phone:937-833-4582
Mailing Address - Fax:937-833-5359
Practice Address - Street 1:950 SALEM ST
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:OH
Practice Address - Zip Code:45309-8227
Practice Address - Country:US
Practice Address - Phone:937-833-4582
Practice Address - Fax:937-833-5359
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.097027207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0086881Medicaid
OH0086881Medicaid