Basic Information
| Provider Information | |||||||||
| NPI: | 1497737639 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DALSASO | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6428 | ||||||||
| Address2: | HUMBOLDT RADIOLOGY MEDICAL GROUP,INC. | ||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955026428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074427814 | ||||||||
| FaxNumber: | 7074453710 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 DOLBEER ST | ||||||||
| Address2: | ST. JOSEPH HOSPITAL | ||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955014736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074427814 | ||||||||
| FaxNumber: | 7074453710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 05/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 224783 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | J28834 | 01 | MA | BCBS MA | OTHER | 2106582 | 05 | MA | MEDICAID | 478702 | 01 | MA | TUFTS HEALTH PLAN | OTHER | A101314 | 01 | CA | MEDICAL LICENSE | OTHER |