Provider Demographics
NPI:1639146194
Name:DILLINGHAM, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:DILLINGHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18275 PRATT RD
Mailing Address - Street 2:
Mailing Address - City:ARMADA
Mailing Address - State:MI
Mailing Address - Zip Code:48005-1153
Mailing Address - Country:US
Mailing Address - Phone:586-784-8207
Mailing Address - Fax:
Practice Address - Street 1:2601 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6587
Practice Address - Country:US
Practice Address - Phone:810-985-1580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002794363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F36241P23Medicare ID - Type Unspecified
MIP21524Medicare UPIN