Provider Demographics
NPI:1639130164
Name:DILLER, JONATHAN F (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:F
Last Name:DILLER
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:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-0378
Mailing Address - Country:US
Mailing Address - Phone:419-609-1112
Mailing Address - Fax:419-609-1123
Practice Address - Street 1:1479 N RIVER RD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420
Practice Address - Country:US
Practice Address - Phone:419-332-9978
Practice Address - Fax:419-332-7989
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-01
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-045285207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000110993OtherANTHEM
OH0437049Medicaid
OH0004312244OtherAETNA
OH0437049Medicaid
OH0004312244OtherAETNA
OH0499932Medicare ID - Type Unspecified
OH000000110993OtherANTHEM