Basic Information
| Provider Information | |||||||||
| NPI: | 1588819569 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DILL | ||||||||
| FirstName: | MALLORRE | ||||||||
| MiddleName: | RAESCHELL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744647017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184444000 | ||||||||
| FaxNumber: | 9184582104 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744647017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184444000 | ||||||||
| FaxNumber: | 9184582104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2008 | ||||||||
| LastUpdateDate: | 08/18/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2555 | OK | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.