Provider Demographics
NPI:1720034523
Name:DALLARA, JOHN J (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:DALLARA
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 1:426 WYATT DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-1054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:142 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-2922
Practice Address - Country:US
Practice Address - Phone:919-810-9971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043027207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005885833Medicaid
VA010313881Medicaid
NC89064Y6Medicaid
VAP00342773OtherRAILROAD MEDICARE
VAP00342773OtherRAILROAD MEDICARE
NC89064Y6Medicaid
E67537Medicare UPIN
VA005885833Medicaid
VA010313881Medicaid