Provider Demographics
NPI:1942668397
Name:JERRY DILLARD MD
Entity Type:Organization
Organization Name:JERRY DILLARD MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:DILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-875-7406
Mailing Address - Street 1:206 W DALLAS AVE
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-6531
Mailing Address - Country:US
Mailing Address - Phone:334-875-7406
Mailing Address - Fax:
Practice Address - Street 1:206 W DALLAS AVE
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-6531
Practice Address - Country:US
Practice Address - Phone:334-875-7406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-31
Last Update Date:2016-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALACSC3813261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty