Provider Demographics
NPI:1558470401
Name:DILLAVOU, NICHOL K (OD)
Entity Type:Individual
Prefix:
First Name:NICHOL
Middle Name:K
Last Name:DILLAVOU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:NICHOL
Other - Middle Name:K
Other - Last Name:DILLAVOU GOETZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2821 ROCK ISLAND PL
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-7720
Mailing Address - Country:US
Mailing Address - Phone:701-471-0465
Mailing Address - Fax:
Practice Address - Street 1:2821 ROCK ISLAND PL
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504
Practice Address - Country:US
Practice Address - Phone:701-471-0465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND591152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60566Medicaid
ND60566Medicaid
N20236Medicare ID - Type Unspecified