Healthcare Provider Details

I. General information

NPI: 1861653255
Provider Name (Legal Business Name): JOHN RAY TALLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 EL CAMINO REAL
PALO ALTO CA
94301-2302
US

IV. Provider business mailing address

795 EL CAMINO REAL
PALO ALTO CA
94301-2302
US

V. Phone/Fax

Practice location:
  • Phone: 650-853-2916
  • Fax:
Mailing address:
  • Phone: 650-853-2916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number49308
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number49308
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number49308
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number49308
License Number StateAZ
# 5
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA110607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: