Provider Demographics
NPI:1922191329
Name:DALLOS, GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:DALLOS
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 1:20 HOPE AVE
Mailing Address - Street 2:SUITE G06
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453
Mailing Address - Country:US
Mailing Address - Phone:781-894-2996
Mailing Address - Fax:781-647-5996
Practice Address - Street 1:20 HOPE AVE
Practice Address - Street 2:SUITE G06
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453
Practice Address - Country:US
Practice Address - Phone:781-894-2996
Practice Address - Fax:781-647-5996
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA49093208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
J02260OtherBCBS
049093OtherTUFTS
D88308Medicare UPIN
MA0190209Medicare ID - Type Unspecified