Provider Demographics
NPI:1063505360
Name:DALY, JACK (DPM)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:DALY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-0002
Mailing Address - Country:US
Mailing Address - Phone:781-322-7716
Mailing Address - Fax:781-322-7727
Practice Address - Street 1:253 SALEM ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-4118
Practice Address - Country:US
Practice Address - Phone:781-322-7716
Practice Address - Fax:781-322-7727
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2149213EP1101X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0326534Medicaid
MAU81496Medicare UPIN
MA3875390001Medicare NSC
MAY75086Medicare PIN