Healthcare Provider Details

I. General information

NPI: 1164043063
Provider Name (Legal Business Name): DANIEL THOMAS TALLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 ROBESON ST STE 203
FAYETTEVILLE NC
28305-5641
US

IV. Provider business mailing address

323 DEVANE ST
FAYETTEVILLE NC
28305-5202
US

V. Phone/Fax

Practice location:
  • Phone: 910-615-3220
  • Fax:
Mailing address:
  • Phone: 229-869-7635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2025-03399
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: