Provider Demographics
NPI:1003850496
Name:DALLIS, JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:DALLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 BOATNER RD STE 114
Mailing Address - Street 2:
Mailing Address - City:EGLIN AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32542-1302
Mailing Address - Country:US
Mailing Address - Phone:850-883-8600
Mailing Address - Fax:
Practice Address - Street 1:307 BOATNER RD STE 114
Practice Address - Street 2:
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-1302
Practice Address - Country:US
Practice Address - Phone:850-883-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA071483207X00000X, 207X00000X
NC9700046207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0003174622GMedicaid
G61101Medicare UPIN
GAAPPLIED FORMedicare PIN
2247364CMedicare PIN
NC891080GMedicaid
7873831OtherCIGNA
1080GOtherBCBS
187761OtherMEDCOST
P00336782OtherMEDICARE RAILROAD
G61101Medicare UPIN