Basic Information
| Provider Information | |||||||||
| NPI: | 1831294578 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DALLER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 MEDICAL CENTER BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | UPLAND | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106198420 | ||||||||
| FaxNumber: | 6106198421 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 MEDICAL CENTER BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | UPLAND | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106198420 | ||||||||
| FaxNumber: | 6106198421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 02/06/2013 | ||||||||
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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 | 208600000X | MD058852L | PA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1017210240001 | 05 | PA | MEDICAID |