Provider Demographics
NPI:1396790721
Name:DILLARD, CAROLYN M (DO)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
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 1:109 POINTER TRL W
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-2236
Mailing Address - Country:US
Mailing Address - Phone:479-922-2222
Mailing Address - Fax:479-922-2227
Practice Address - Street 1:109 POINTER TRL W
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-2236
Practice Address - Country:US
Practice Address - Phone:479-922-2222
Practice Address - Fax:479-922-2227
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2427207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR139925003Medicaid
AR5L400Medicare ID - Type UnspecifiedARKANSAS MEDICARE
AR139925003Medicaid