Provider Demographics
NPI:1639253248
Name:DILLON, EVAN H (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:H
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 1:92 FIESTA WAY
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-1415
Mailing Address - Country:US
Mailing Address - Phone:917-968-9975
Mailing Address - Fax:
Practice Address - Street 1:92 FIESTA WAY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-1415
Practice Address - Country:US
Practice Address - Phone:917-968-9975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1662892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY677U61OtherEMPIRE BCBS
NY01079065Medicaid
NJ6363008Medicaid
NY61H331Medicare PIN
NYP000171244Medicare PIN
NYE44202Medicare UPIN
NJ6363008Medicaid
NY01079065Medicaid
NY61H33TG231Medicare PIN