Healthcare Provider Details

I. General information

NPI: 1124091475
Provider Name (Legal Business Name): WILLARD T DALTON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 06/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8166 MAIN STREET
HOUMA LA
70360
US

IV. Provider business mailing address

PO BOX 6037
HOUMA LA
70361-6037
US

V. Phone/Fax

Practice location:
  • Phone: 985-873-4141
  • Fax: 985-851-4307
Mailing address:
  • Phone: 985-873-4235
  • Fax: 985-851-4307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberMD08126R
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD08126R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: