Provider Demographics
NPI:1801058169
Name:DALTON, BRIAN GALEN ANDREW (MD,)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:GALEN ANDREW
Last Name:DALTON
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11945 SAN JOSE BLVD
Mailing Address - Street 2:STE 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-396-4893
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-383-1015
Practice Address - Fax:904-244-3870
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD454268208600000X
OH35.122372208600000X
SCLL30950208600000X
FLME126414208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCLL30950OtherSOUTH CAROLINA BOARD OF MEDICAL EXAMINER'S
FLME126414OtherFLORIDA BOARD OF MEDICINE
OH57.022483OtherTRAINING CERTIFICATE
PAMD454268OtherPENNSYLVANIA MEDICAL BOARD