Provider Demographics
NPI:1285633867
Name:LALLY, JAMES M (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:LALLY
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:13193 CENTRAL AVE
Mailing Address - Street 2:STE. 100
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-4179
Mailing Address - Country:US
Mailing Address - Phone:909-464-9675
Mailing Address - Fax:909-590-3898
Practice Address - Street 1:13193 CENTRAL AVE
Practice Address - Street 2:STE. 100
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-4179
Practice Address - Country:US
Practice Address - Phone:909-464-9675
Practice Address - Fax:909-590-3898
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2017-09-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA20A6259207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1285633867Medicaid
CA020A62592Medicare ID - Type UnspecifiedMEDICARE
CA1285633867Medicaid
CAF46671Medicare UPIN