Healthcare Provider Details

I. General information

NPI: 1275162190
Provider Name (Legal Business Name): KIARA LASHAE DILLARD-DORVE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-8664
  • Fax: 414-955-0064
Mailing address:
  • Phone: 414-955-8664
  • Fax: 414-955-0064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.164893
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number77059
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: