Provider Demographics
NPI:1780684639
Name:DALLE, JOHN GREGORY (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GREGORY
Last Name:DALLE
Suffix:
Gender:M
Credentials:DO
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 101418
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91189-0025
Mailing Address - Country:US
Mailing Address - Phone:844-866-2718
Mailing Address - Fax:310-966-8571
Practice Address - Street 1:801 S MAIN ST STE 101&205
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-3402
Practice Address - Country:US
Practice Address - Phone:951-238-6071
Practice Address - Fax:951-351-1025
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN546762085R0202X
CA20A84412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00126987OtherRAILROAD
CA00AX84410Medicaid
CA020A84410OtherBLUE SHIELD
CA00AX84410Medicaid
CA020A84410Medicare PIN