Provider Demographics
NPI:1043533649
Name:I D SPECIALIST DALTON P C
Entity Type:Organization
Organization Name:I D SPECIALIST DALTON P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALMYTH
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROJAS
Authorized Official - Suffix:
Authorized Official - Credentials:BBA, PCP
Authorized Official - Phone:706-428-8908
Mailing Address - Street 1:1200 E WALNUT AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30721-4191
Mailing Address - Country:US
Mailing Address - Phone:706-428-8908
Mailing Address - Fax:
Practice Address - Street 1:1200 E WALNUT AVE STE 4
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-4191
Practice Address - Country:US
Practice Address - Phone:706-428-8908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046533207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251036700Medicaid
FLBK595AMedicare PIN