Provider Demographics
NPI:1912900648
Name:DALTON, TIMOTHY JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:DALTON
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 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-759-7596
Mailing Address - Fax:336-759-3652
Practice Address - Street 1:1995 BETHABARA RD
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3375
Practice Address - Country:US
Practice Address - Phone:336-759-7596
Practice Address - Fax:336-759-3652
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500876207Q00000X
NC95-00876208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
0402121OtherUNITED HEALTHCARE
NC8926793Medicaid
5592041OtherAETNA PPO POS
287316OtherMAMSI
58523OtherMEDCOST
10526OtherPARTNERS
2624358OtherAETNA HMO OPOS
26793OtherBCBS
410250659OtherCHAMPUS
110113235OtherRAILROAD MEDICARE
110113235OtherRAILROAD MEDICARE
410250659OtherCHAMPUS
NC8926793Medicaid