Provider Demographics
NPI:1649252362
Name:DILLON, KRISTEN GAIL (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:GAIL
Last Name:DILLON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2965 NE CONNERS AVE
Mailing Address - Street 2:PACIFICSOURCE HEALTH SERVICES DEPAR
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7753
Mailing Address - Country:US
Mailing Address - Phone:541-385-5315
Mailing Address - Fax:
Practice Address - Street 1:2965 NE CONNERS AVE
Practice Address - Street 2:PACIFICSOURCE HEALTH SERVICES DEPAR
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7753
Practice Address - Country:US
Practice Address - Phone:541-385-5315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2016-02-20
Deactivation Date:2005-11-17
Deactivation Code:
Reactivation Date:2005-11-23
Provider Licenses
StateLicense IDTaxonomies
ORMD22417207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
80169500OtherRAILROAD MEDICARE
WA8278426Medicaid
1978033OtherUNITED MEDICAL PLAN
OR288186Medicaid
OR11007OtherBLUE CROSS BLUE SHIELD
WA150654OtherDEPT OF LABOR AND INDUSTR
K5099 06OtherPACIFICSOURCE
80169500OtherRAILROAD MEDICARE
OR11007OtherBLUE CROSS BLUE SHIELD