Provider Demographics
NPI:1831294578
Name:DALLER, JOHN A (MD, PHD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:A
Last Name:DALLER
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:UPLAND
Mailing Address - State:PA
Mailing Address - Zip Code:19013
Mailing Address - Country:US
Mailing Address - Phone:610-619-8420
Mailing Address - Fax:610-619-8421
Practice Address - Street 1:30 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:UPLAND
Practice Address - State:PA
Practice Address - Zip Code:19013
Practice Address - Country:US
Practice Address - Phone:610-619-8420
Practice Address - Fax:610-619-8421
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD058852L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017210240001Medicaid
PA103938Medicare PIN