Provider Demographics
NPI:1639262181
Name:MORGAN, DALLAS RENARD (DPM)
Entity Type:Individual
Prefix:DR
First Name:DALLAS
Middle Name:RENARD
Last Name:MORGAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 STATHAMS WAY
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088
Mailing Address - Country:US
Mailing Address - Phone:478-922-7032
Mailing Address - Fax:
Practice Address - Street 1:104 PATRIOT WAY
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088
Practice Address - Country:US
Practice Address - Phone:478-922-0448
Practice Address - Fax:478-922-7944
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000490213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00294082EMedicaid
GA00294082EMedicaid
48SCCFPMedicare ID - Type Unspecified