Basic Information
| Provider Information | |||||||||
| NPI: | 1770583239 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DALAL | ||||||||
| FirstName: | AJAY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 1000 DEPT 960 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017630200 | ||||||||
| FaxNumber: | 9017614002 | ||||||||
| Practice Location | |||||||||
| Address1: | 7460 WOLF RIVER BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017630200 | ||||||||
| FaxNumber: | 9017614002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2005 | ||||||||
| LastUpdateDate: | 03/16/2018 | ||||||||
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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 | 207RC0000X | E-5634 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 18205 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 36866 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 00124888 | 05 | MS | MEDICAID | 4270109 | 01 | TN | BCBS | OTHER | 149021001 | 05 | AR | MEDICAID | 3879360 | 05 | TN | MEDICAID |