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General NPI Number Information
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NPI Number | 1942668397
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Entity Type | Organization
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Legal Business Name | JERRY DILLARD MD
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Dates
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Enumeration Date | 01/31/2016
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Last Update Date | 01/31/2016
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Provider Practice Location Address
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Address Line | 206 W DALLAS AVE
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City | SELMA
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State | AL
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Zip | 36701-6531
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Country | US
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Telephone | 334-875-7406
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Fax |
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Provider Business Mailing Address
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Address Line | 206 W DALLAS AVE
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City | SELMA
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State | AL
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Zip | 36701-6531
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Country | US
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Telephone | 334-875-7406
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JERRY DEAN DILLARD
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Credential | M.D.
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Telephone | 334-875-7406
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | ACSC3813
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License Number State | AL
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