Provider Demographics
NPI:1598730020
Name:DILLON, SHERESE R (DPM)
Entity type:Individual
Prefix:MS
First Name:SHERESE
Middle Name:R
Last Name:DILLON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1237 W 82ND LANE
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410
Mailing Address - Country:US
Mailing Address - Phone:219-791-0667
Mailing Address - Fax:219-791-0657
Practice Address - Street 1:1237 W 82ND LANE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410
Practice Address - Country:US
Practice Address - Phone:219-791-0667
Practice Address - Fax:219-791-0657
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-19
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000980A213E00000X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200281060AMedicaid
IN200281060AMedicaid
IN221630Medicare ID - Type Unspecified
INU92703Medicare UPIN