Provider Demographics
NPI:1780684639
Name:DALLE, JOHN GREGORY (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GREGORY
Last Name:DALLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1450 NW 6035
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55485-6035
Mailing Address - Country:US
Mailing Address - Phone:800-634-4064
Mailing Address - Fax:952-513-6880
Practice Address - Street 1:166 19TH STREET SOUTH
Practice Address - Street 2:SUITE 100
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2154
Practice Address - Country:US
Practice Address - Phone:320-251-0609
Practice Address - Fax:320-251-3806
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN546762085R0202X
CA20A84412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX84410Medicaid
CAP00126987OtherRAILROAD
CA020A84410OtherBLUE SHIELD
CA00AX84410Medicaid
CA020A84410Medicare PIN