Basic Information
| Provider Information | |||||||||
| NPI: | 1619947082 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DALTON | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 250 S END AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 102801078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185206620 | ||||||||
| FaxNumber: | 7185206630 | ||||||||
| Practice Location | |||||||||
| Address1: | 106-14 70TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185206620 | ||||||||
| FaxNumber: | 7185206630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 01/11/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 112564 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 113089245 | 01 | NY | TAX ID | OTHER | NS1640 | 01 | NY | OXFORD HEALTHCARE | OTHER | 176007 | 01 | NY | ELDERPLAN | OTHER | 24706P | 01 | NY | HIP | OTHER | 4C8348 | 01 | NY | HEALTHNET | OTHER | 0041437 | 01 | NY | GHI | OTHER | 00881847 | 05 | NY | MEDICAID |