MEDICARE: CHARLES O DILLARD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	35-029778	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346251725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES O DILLARD

Provider Business Mailing Address
First Line	:	2450 KIPLING AVE
Second Line	:	SUITE 108
City	:	CINCINNATI
State	:	OH
Zip	:	45239-6600
Country	:	US
Telephone Number	:	513-853-5393
Fax Number	:	513-853-5394

Provider Business Practice Location Address
First Line	:	2450 KIPLING AVE
Second Line	:	SUITE 108
City	:	CINCINNATI
State	:	OH
Zip	:	45239-6600
Country	:	US
Telephone Number	:	513-853-5393
Fax Number	:	513-853-5394

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	08/15/2011

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Directions to “ CHARLES O DILLARD ” Practice Location

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