Healthcare Provider Details

I. General information

NPI: 1780818112
Provider Name (Legal Business Name): ETHAN BERNELL DALLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3419 22ND ST
LUBBOCK TX
79410
US

IV. Provider business mailing address

3419 22ND ST
LUBBOCK TX
79410-1334
US

V. Phone/Fax

Practice location:
  • Phone: 806-796-3000
  • Fax: 806-796-3006
Mailing address:
  • Phone: 806-796-3000
  • Fax: 806-796-3006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberP9063
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: