Provider Demographics
NPI:1801892054
Name:DALLE-AVE, MARK JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
Last Name:DALLE-AVE
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 850
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-0850
Mailing Address - Country:US
Mailing Address - Phone:423-272-5202
Mailing Address - Fax:423-272-4696
Practice Address - Street 1:4307 HIGHWAY 66 S
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37857-3155
Practice Address - Country:US
Practice Address - Phone:423-921-1600
Practice Address - Fax:423-921-1677
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25875207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4057107OtherBCBST
TN3085703Medicaid
3085705Medicare PIN
30857031Medicare PIN
F89268Medicare UPIN
TN4057107OtherBCBST
TN3085703Medicaid
3085705Medicare ID - Type Unspecified
3716673Medicare PIN