Provider Demographics
NPI:1356393482
Name:DALLAS, STEPHEN N (MD, MA)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:N
Last Name:DALLAS
Suffix:
Gender:M
Credentials:MD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-9538
Mailing Address - Country:US
Mailing Address - Phone:269-383-6789
Mailing Address - Fax:269-383-6767
Practice Address - Street 1:3601 S 9TH ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-9538
Practice Address - Country:US
Practice Address - Phone:269-383-6789
Practice Address - Fax:269-383-6767
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067063207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4236764Medicaid
G89378Medicare UPIN
MI4236764Medicaid
MI0P20550002Medicare PIN