Provider Demographics
NPI:1376588061
Name:DALLY, ALFREDO DEJESUS (MD)
Entity Type:Individual
Prefix:DR
First Name:ALFREDO
Middle Name:DEJESUS
Last Name:DALLY
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 1:8120 NW 167TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-6189
Mailing Address - Country:US
Mailing Address - Phone:305-269-8099
Mailing Address - Fax:305-261-3250
Practice Address - Street 1:7650 W FLAGLER ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2406
Practice Address - Country:US
Practice Address - Phone:305-265-7955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88433174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH94354Medicare UPIN
FLU1357ZMedicare ID - Type Unspecified