Healthcare Provider Details

I. General information

NPI: 1366585713
Provider Name (Legal Business Name): LOUISE ISENBERG DALLAIRE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 MAIN ST
OLEAN NY
14760-1513
US

IV. Provider business mailing address

1116 ARSENAL ST SUITE #504
WATERTOWN NY
13601-2229
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-2620
  • Fax:
Mailing address:
  • Phone: 315-782-2620
  • Fax: 315-788-4980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number164861-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: