Provider Demographics
NPI:1023123478
Name:DALLAS, JOHN S (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:DALLAS
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:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-7960
Practice Address - Fax:682-885-1327
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH71352080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00257TOtherMEDICARE GROUP
1750369203OtherGRP NPI NUMBER
TX150220509OtherCSHCN GROUP
TX137011611Medicaid
TX137011612OtherCSHCN
TX137011617Medicaid
TX150220508OtherMEDICAID GROUP
TX00U87ZOtherMEDICARE GROUP
TX00257TOtherMEDICARE GROUP
TX150220508OtherMEDICAID GROUP