Provider Demographics
NPI:1053318824
Name:DALTON, STEPHEN LEWIS (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LEWIS
Last Name:DALTON
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 1:400 PROFESSIONAL CENTER DR
Mailing Address - Street 2:SUITE 414
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-4367
Mailing Address - Country:US
Mailing Address - Phone:415-892-0754
Mailing Address - Fax:415-897-3204
Practice Address - Street 1:400 PROFESSIONAL CENTER DR
Practice Address - Street 2:SUITE 414
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-4367
Practice Address - Country:US
Practice Address - Phone:415-892-0754
Practice Address - Fax:415-897-3204
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62214207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00429886OtherRAILROAD MEDICARE
CA00A622144Medicare PIN
CAP00429886OtherRAILROAD MEDICARE