Basic Information
| Provider Information | |||||||||
| NPI: | 1225013311 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DILLARD | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | ROSS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1547 | ||||||||
| Address2: | |||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653021547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608265960 | ||||||||
| FaxNumber: | 6608264852 | ||||||||
| Practice Location | |||||||||
| Address1: | 8000 AL HIGHWAY 69 | ||||||||
| Address2: | MARSHALL COUNTY MEDICAL CENTER NORTH | ||||||||
| City: | GUNTERSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359767140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565718000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2005 | ||||||||
| LastUpdateDate: | 10/20/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 13066 | AL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 050091764 | 01 | TRAVELERS MEDICARE | OTHER | 300117300 | 01 | UMWA MEDICARE | OTHER | 051512175 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 051512175 | 05 | AL | MEDICAID | 2000417 | 01 | UNITED HEALTHCARE | OTHER |