Provider Demographics
NPI:1548202088
Name:DALLY, PAUL D (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:D
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:PO BOX 23200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97281-3200
Mailing Address - Country:US
Mailing Address - Phone:360-213-9955
Mailing Address - Fax:
Practice Address - Street 1:505 NE 87TH AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1989
Practice Address - Country:US
Practice Address - Phone:360-213-9955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024635208600000X
OROR42136208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR277847Medicaid
WA1029172Medicaid
WA1029172Medicaid
ORR131292Medicare PIN
WAG8859345Medicare PIN
ORA08104Medicare UPIN
OR277847Medicaid