Provider Demographics
NPI:1659307569
Name:LA SALLE, DILLIAN (MD)
Entity Type:Individual
Prefix:
First Name:DILLIAN
Middle Name:
Last Name:LA SALLE
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 1:635 E BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-6551
Mailing Address - Country:US
Mailing Address - Phone:602-243-7277
Mailing Address - Fax:602-243-1235
Practice Address - Street 1:635 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6551
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:602-243-1235
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25273207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ381624Medicaid
AZF22805Medicare UPIN