Provider Demographics
NPI:1235331455
Name:DALIA, SAMIR MUKUNDRAY (MD)
Entity Type:Individual
Prefix:
First Name:SAMIR
Middle Name:MUKUNDRAY
Last Name:DALIA
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 1:100 MERCY WAY
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4524
Mailing Address - Country:US
Mailing Address - Phone:417-782-7722
Mailing Address - Fax:417-556-3098
Practice Address - Street 1:100 MERCY WAY
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4524
Practice Address - Country:US
Practice Address - Phone:417-782-7722
Practice Address - Fax:417-556-3098
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014012975207RH0003X
RILP01096207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01359270OtherRAIL ROAD MEDICARE
OK200551580AMedicaid
KS201101460AMedicaid
MO1235331455Medicaid
MOMA2082402Medicare PIN