Provider Demographics
NPI:1629071873
Name:DALLEY, GARY M (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:DALLEY
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 1:2130 IMPERIAL DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-1315
Mailing Address - Country:US
Mailing Address - Phone:770-287-1144
Mailing Address - Fax:
Practice Address - Street 1:1515 RIVER PL
Practice Address - Street 2:SUITE 200
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-5602
Practice Address - Country:US
Practice Address - Phone:770-848-6140
Practice Address - Fax:770-848-6141
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045760207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000798322EMedicaid
GA000798322CMedicaid
GA00798322BMedicaid
GA11SCFVDMedicare PIN
GA00798322BMedicaid
GA000798322CMedicaid
GAG74997Medicare UPIN