Provider Demographics
NPI:1598869711
Name:DILLON, RICHARD TERRENCE (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:TERRENCE
Last Name:DILLON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TERRENCE
Other - Middle Name:
Other - Last Name:DILLON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5450 FAR HILLS AVE
Mailing Address - Street 2:SUITE 124
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2386
Mailing Address - Country:US
Mailing Address - Phone:937-435-2920
Mailing Address - Fax:937-435-2190
Practice Address - Street 1:1 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2722
Practice Address - Country:US
Practice Address - Phone:937-208-2907
Practice Address - Fax:937-208-5415
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35039864D2080P0202X
OH35.039864208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0598509Medicaid
1247729OtherBLUE PROVIDER NUMBER
1247729OtherBLUE PROVIDER NUMBER
0593512Medicare PIN
OH0598509Medicaid