Healthcare Provider Details

I. General information

NPI: 1750420345
Provider Name (Legal Business Name): JATIN J DALAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 W HOSPITALITY LN STE 400
SAN BERNARDINO CA
92415-0001
US

IV. Provider business mailing address

268 W HOSPITALITY LN STE 400
SAN BERNARDINO CA
92415-0001
US

V. Phone/Fax

Practice location:
  • Phone: 909-382-3087
  • Fax: 909-382-3106
Mailing address:
  • Phone: 909-382-3087
  • Fax: 909-382-3106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA49065
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberA49065
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: