Healthcare Provider Details

I. General information

NPI: 1497737639
Provider Name (Legal Business Name): TIMOTHY JOHN DALSASO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 05/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 DOLBEER ST ST. JOSEPH HOSPITAL
EUREKA CA
95501-4736
US

IV. Provider business mailing address

PO BOX 6428 HUMBOLDT RADIOLOGY MEDICAL GROUP,INC.
EUREKA CA
95502-6428
US

V. Phone/Fax

Practice location:
  • Phone: 707-442-7814
  • Fax: 707-445-3710
Mailing address:
  • Phone: 707-442-7814
  • Fax: 707-445-3710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number224783
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: