Provider Demographics
NPI:1760769400
Name:DILLAHA, LARRY (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:DILLAHA
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 1:2046 BRECKENRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-6305
Mailing Address - Country:US
Mailing Address - Phone:615-767-0074
Mailing Address - Fax:
Practice Address - Street 1:2046 BRECKENRIDGE DR
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-6305
Practice Address - Country:US
Practice Address - Phone:615-767-0074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD24875208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice