Provider Demographics
NPI:1609825645
Name:DILLARD, LORI A (DO)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:A
Last Name:DILLARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15300 21 MILE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-5024
Mailing Address - Country:US
Mailing Address - Phone:586-799-7682
Mailing Address - Fax:586-799-7827
Practice Address - Street 1:15300 21 MILE RD STE 3
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044
Practice Address - Country:US
Practice Address - Phone:586-799-7682
Practice Address - Fax:586-799-7827
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014290204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4435928Medicaid
MI4435928Medicaid