Provider Demographics
NPI:1659324234
Name:DILLARD, J WAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:J WAYNE
Middle Name:
Last Name:DILLARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2170 S EL CAMINO REAL
Mailing Address - Street 2:SUITE 117-122
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-6203
Mailing Address - Country:US
Mailing Address - Phone:760-730-8060
Mailing Address - Fax:888-857-5957
Practice Address - Street 1:2170 S EL CAMINO REAL
Practice Address - Street 2:SUITE 117-122
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6203
Practice Address - Country:US
Practice Address - Phone:760-730-8060
Practice Address - Fax:888-857-5957
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA60425204D00000X, 208100000X, 2081P2900X
ME1820204D00000X, 208100000X, 2081P2900X
CA20A5941204D00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432162000Medicaid
MAD99887Medicare UPIN
MAJ08448Medicare ID - Type Unspecified