Provider Demographics
NPI:1629119383
Name:DILLON, ROBERT RANDY (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:RANDY
Last Name:DILLON
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 1:2550 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-5906
Mailing Address - Country:US
Mailing Address - Phone:702-453-3799
Mailing Address - Fax:702-453-5741
Practice Address - Street 1:2400 EDISON ST
Practice Address - Street 2:
Practice Address - City:BRUSH
Practice Address - State:CO
Practice Address - Zip Code:80723-1640
Practice Address - Country:US
Practice Address - Phone:702-453-3799
Practice Address - Fax:702-453-5741
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35220207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO78054222Medicaid
COC527018Medicare PIN
COG27962Medicare UPIN