Provider Demographics
NPI:1396729505
Name:DIAL, ALPHONSO LANE (MD)
Entity type:Individual
Prefix:DR
First Name:ALPHONSO
Middle Name:LANE
Last Name:DIAL
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 1:122 DEFENSE HWY
Mailing Address - Street 2:CHESAPEAKE MEDICAL IMAGING
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7069
Mailing Address - Country:US
Mailing Address - Phone:410-571-0350
Mailing Address - Fax:
Practice Address - Street 1:122 DEFENSE HWY
Practice Address - Street 2:CHESAPEAKE MEDICAL IMAGING
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7069
Practice Address - Country:US
Practice Address - Phone:410-571-0350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00389082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
470001526OtherRR MEDICARE
MD407193000Medicaid
016879W30OtherUNSPECIFIED
MD407193000Medicaid
MD575P181HMedicare PIN
E39931Medicare UPIN
MD784ML219Medicare PIN
DC013932O31Medicare PIN