1780684639 NPI number — DR. JOHN GREGORY DALLE D.O.

Table of content: DR. JOHN GREGORY DALLE D.O. (NPI 1780684639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780684639 NPI number — DR. JOHN GREGORY DALLE D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DALLE
Provider First Name:
JOHN
Provider Middle Name:
GREGORY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1780684639
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1450 NW 6035
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55485-6035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-634-4064
Provider Business Mailing Address Fax Number:
952-513-6880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
166 19TH STREET SOUTH
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SARTELL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56377-2154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-251-0609
Provider Business Practice Location Address Fax Number:
320-251-3806
Provider Enumeration Date:
07/21/2005

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: 2085R0202X , with the licence number:  54676 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0202X , with the licence number: 20A8441 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00AX84410 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00126987 . This is a "RAILROAD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 020A84410 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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