Provider Demographics
NPI:1891085288
Name:DILLARD, MARK J (HAD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
Last Name:DILLARD
Suffix:
Gender:M
Credentials:HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8800 SE SUNNYSIDE RD
Mailing Address - Street 2:STE. 300-N
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5738
Mailing Address - Country:US
Mailing Address - Phone:503-659-5115
Mailing Address - Fax:
Practice Address - Street 1:940 BATTLEFIELD PKWY
Practice Address - Street 2:
Practice Address - City:FT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-4044
Practice Address - Country:US
Practice Address - Phone:706-858-0466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAHADE03490237700000X
TN0000000712237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist