Healthcare Provider Details

I. General information

NPI: 1669455515
Provider Name (Legal Business Name): THOMAS G DALLMAN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 RAMAR RD SUITE 12
BULLHEAD CITY AZ
86442-7100
US

IV. Provider business mailing address

1355 RAMAR RD SUITE 12
BULLHEAD CITY AZ
86442-7100
US

V. Phone/Fax

Practice location:
  • Phone: 928-763-9505
  • Fax: 928-763-7370
Mailing address:
  • Phone: 928-763-9505
  • Fax: 928-763-7370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number16390
License Number StateAZ

VIII. Authorized Official

Name: DR. THOMAS GARY DALLMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 928-763-9505