Provider Demographics
NPI:1497737639
Name:DALSASO, TIMOTHY JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:DALSASO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6428
Mailing Address - Street 2:HUMBOLDT RADIOLOGY MEDICAL GROUP,INC.
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95502-6428
Mailing Address - Country:US
Mailing Address - Phone:707-442-7814
Mailing Address - Fax:707-445-3710
Practice Address - Street 1:2700 DOLBEER ST
Practice Address - Street 2:ST. JOSEPH HOSPITAL
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4736
Practice Address - Country:US
Practice Address - Phone:707-442-7814
Practice Address - Fax:707-445-3710
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2247832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ28834OtherBCBS MA
MA2106582Medicaid
MA478702OtherTUFTS HEALTH PLAN
CAA101314OtherMEDICAL LICENSE
MAJ28834OtherBCBS MA
I32617Medicare UPIN