Provider Demographics
NPI:1013923119
Name:DILLON, GARY P (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:P
Last Name:DILLON
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:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:1500 SALEM ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2164
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-448-7029
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024462A207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000340592OtherANTHEM
IN100340440Medicaid
IN000000705135OtherANTHEM PROVIDER PIN / TIN 35-2030653
INP01000910Medicare PIN
D69420Medicare UPIN
INM400046319Medicare PIN
IN000000340592OtherANTHEM
INP00186398Medicare PIN