MEDICARE: DR. DALLAS A LEA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2081P0004X	Spinal Cord Injury Medicine Physician	D59136	MD
2	2081P0004X	Spinal Cord Injury Medicine Physician	MD33523	DC
3	2081P0004X	Spinal Cord Injury Medicine Physician	L3375	TX

General Provider Information

NPI Number	:	1063420750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DALLAS A LEA M.D.

Provider Business Mailing Address
First Line	:	1400 SPRING ST
Second Line	:	SUITE 400
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-2735
Country	:	US
Telephone Number	:	301-495-3742
Fax Number	:	301-495-3743

Provider Business Practice Location Address
First Line	:	1400 SPRING ST
Second Line	:	SUITE 400
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-2735
Country	:	US
Telephone Number	:	301-495-3742
Fax Number	:	301-495-3743

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	04/01/2015

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