Provider Demographics
NPI:1619947082
Name:DALTON, JACK F (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:F
Last Name:DALTON
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 1:250 S END AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10280-1078
Mailing Address - Country:US
Mailing Address - Phone:718-520-6620
Mailing Address - Fax:718-520-6630
Practice Address - Street 1:106-14 70TH AVENUE
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375
Practice Address - Country:US
Practice Address - Phone:718-520-6620
Practice Address - Fax:718-520-6630
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112564174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY113089245OtherTAX ID
NYNS1640OtherOXFORD HEALTHCARE
NY176007OtherELDERPLAN
NY24706POtherHIP
NY4C8348OtherHEALTHNET
NY0041437OtherGHI
NY00881847Medicaid
NYNS1640OtherOXFORD HEALTHCARE
NY00863GMedicare ID - Type UnspecifiedGHI MEDICARE
NY00881847Medicaid