=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396790721
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLYN M DILLARD D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2006
-----------------------------------------------------
Last Update Date | 09/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 POINTER TRL W
-----------------------------------------------------
City | VAN BUREN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72956-2236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-922-2222
-----------------------------------------------------
Fax | 479-922-2227
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 POINTER TRL W
-----------------------------------------------------
City | VAN BUREN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72956-2236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-922-2222
-----------------------------------------------------
Fax | 479-922-2227
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | E2427
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------