1619947082 NPI number — DR. JACK F DALTON M.D.

Table of content: DR. JACK F DALTON M.D. (NPI 1619947082)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619947082 NPI number — DR. JACK F DALTON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DALTON
Provider First Name:
JACK
Provider Middle Name:
F
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619947082
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 S END AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10280-1078
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-520-6620
Provider Business Mailing Address Fax Number:
718-520-6630

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106-14 70TH AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOREST HILLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-520-6620
Provider Business Practice Location Address Fax Number:
718-520-6630
Provider Enumeration Date:
01/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  112564 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 113089245 . This is a "TAX ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: NS1640 . This is a "OXFORD HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 176007 . This is a "ELDERPLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 24706P . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4C8348 . This is a "HEALTHNET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0041437 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00881847 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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