Healthcare Provider Details

I. General information

NPI: 1700834819
Provider Name (Legal Business Name): JOHN WILLIAM DILLOW BA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 SE MOUNT HOOD HWY
GRESHAM OR
97080-9156
US

IV. Provider business mailing address

PO BOX 623
GRESHAM OR
97030-0149
US

V. Phone/Fax

Practice location:
  • Phone: 503-492-8000
  • Fax: 503-492-8444
Mailing address:
  • Phone: 503-492-8000
  • Fax: 503-492-8444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAS-P-063663
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier011465
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier865273000
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerBLUE CROSS BLUE SHEILD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: