Basic Information
| Provider Information | |||||||||
| NPI: | 1891772562 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DILLON | ||||||||
| FirstName: | HAROLD | ||||||||
| MiddleName: | DEXTER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | J. H. QUILLEN VETERANS AFFAIRS MEDICAL CENTER 112E | ||||||||
| Address2: | P.O. BOX 4000 | ||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376844000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239261171 | ||||||||
| FaxNumber: | 4239793530 | ||||||||
| Practice Location | |||||||||
| Address1: | J. H. QUILLEN VETERANS AFFAIRS MEDICAL CENTER 112E | ||||||||
| Address2: | BUILDING 8, DOGWOOD AVENUE | ||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376844000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239261171 | ||||||||
| FaxNumber: | 4239793530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 12/10/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 27768 | SC | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 277685 | 05 | SC | MEDICAID |