Provider Demographics
NPI:1104815364
Name:DILLARD, CAMILLE (DO)
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:DILLARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HOBART ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-4308
Mailing Address - Country:US
Mailing Address - Phone:315-798-1149
Mailing Address - Fax:315-734-3565
Practice Address - Street 1:120 HOBART ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4308
Practice Address - Country:US
Practice Address - Phone:315-798-1149
Practice Address - Fax:315-734-3565
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205458-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02302578Medicaid
NYRA6535Medicare ID - Type UnspecifiedMEDICARE
NY02302578Medicaid