Provider Demographics
NPI:1972561314
Name:DALBOW, MILTON RANDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:MILTON
Middle Name:RANDALL
Last Name:DALBOW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:M
Other - Middle Name:RANDY
Other - Last Name:DALBOW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6210
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-6210
Mailing Address - Country:US
Mailing Address - Phone:505-609-2258
Mailing Address - Fax:
Practice Address - Street 1:1800 PRESERVE AVE W
Practice Address - Street 2:#1826
Practice Address - City:PORT ROYAL
Practice Address - State:SC
Practice Address - Zip Code:29935-2514
Practice Address - Country:US
Practice Address - Phone:724-553-6282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041841L174400000X
SC34452207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012111900001Medicaid
PA110059269OtherRAILROAD MEDICARE
SC344522Medicaid
SC344522Medicaid
PA0012111900001Medicaid
PA616532Medicare PIN