Provider Demographics
NPI:1558327072
Name:DILLARD, DAVID G (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:G
Last Name:DILLARD
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:PO BOX 1728
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-0034
Mailing Address - Country:US
Mailing Address - Phone:706-353-0093
Mailing Address - Fax:706-353-0094
Practice Address - Street 1:1000 HAWTHORNE AVE
Practice Address - Street 2:SUITE O
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2168
Practice Address - Country:US
Practice Address - Phone:706-353-0093
Practice Address - Fax:706-353-0094
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-24
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040364207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA040015437OtherMEDICARE RAILROAD ID NO
GA040364OtherSTATE LICENSE NUMBER
GA00681227KMedicaid
GA196754OtherBCBS PROVIDER NUMBER
GA040364OtherSTATE LICENSE NUMBER
GA040015437OtherMEDICARE RAILROAD ID NO
GAE45092Medicare UPIN