Provider Demographics
NPI:1780818112
Name:DALLEY, ETHAN BERNELL (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:BERNELL
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 1:3419 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1334
Mailing Address - Country:US
Mailing Address - Phone:806-796-3000
Mailing Address - Fax:806-796-3006
Practice Address - Street 1:3419 22ND ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410
Practice Address - Country:US
Practice Address - Phone:806-796-3000
Practice Address - Fax:806-796-3006
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP90632081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty