Basic Information
| Provider Information | |||||||||
| NPI: | 1801058169 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DALTON | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | GALEN ANDREW | ||||||||
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| Credential: | M.D, | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11945 SAN JOSE BLVD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322231627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043961725 | ||||||||
| FaxNumber: | 9043964893 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 W 8TH ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322096511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043831015 | ||||||||
| FaxNumber: | 9042443870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2008 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD454268 | PA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 35.122372 | OH | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | LL30950 | SC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | ME126414 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | LL30950 | 01 | SC | SOUTH CAROLINA BOARD OF MEDICAL EXAMINER'S | OTHER | ME126414 | 01 | FL | FLORIDA BOARD OF MEDICINE | OTHER | 57.022483 | 01 | OH | TRAINING CERTIFICATE | OTHER | MD454268 | 01 | PA | PENNSYLVANIA MEDICAL BOARD | OTHER |