Provider Demographics
NPI:1649243775
Name:DYLLA, MARY JANE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:DYLLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 POPE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENA
Mailing Address - State:CA
Mailing Address - Zip Code:94574-1278
Mailing Address - Country:US
Mailing Address - Phone:707-963-7307
Mailing Address - Fax:
Practice Address - Street 1:1120 POPE ST
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-1278
Practice Address - Country:US
Practice Address - Phone:707-963-7307
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG01743174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF09468Medicare UPIN
CA00G617430Medicare ID - Type UnspecifiedMEDICARE NUMBER