Healthcare Provider Details

I. General information

NPI: 1831153212
Provider Name (Legal Business Name): LISA J. DILLARD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA J. WALKER M.D.

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 CHURCH ST NE STE 250 SUITE 250
MARIETTA GA
30060-8902
US

IV. Provider business mailing address

PO BOX 650
AUSTELL GA
30168-1007
US

V. Phone/Fax

Practice location:
  • Phone: 678-797-8238
  • Fax: 404-588-2655
Mailing address:
  • Phone: 770-941-4810
  • Fax: 770-948-9149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number49219
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: