Provider Demographics
NPI:1568495448
Name:DILLINGHAM, MARK L (PA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:L
Last Name:DILLINGHAM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4207
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-4207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1711 S HENDERSON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3563
Practice Address - Country:US
Practice Address - Phone:903-315-3800
Practice Address - Fax:903-984-5367
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01791363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS93454Medicare UPIN